CMS Halts New Medicare Enrollment for Hospice, Home Care Amid Fraud Crackdown
CMS imposed a six-month nationwide freeze on new Medicare enrollments for hospices and home health agencies as part of a broader crackdown on fraud in the sectors.
‘Prior Authorization’ Has Become a Dirty Word in Healthcare, But it Might Be Medicare’s Smartest Path Forward
Since its inception, AI in prior auth has only been at work in the commercial healthcare marketplace. Now new innovative approaches that reframe prior auth as a resource instead of a roadblock have come to Medicare via the WISeR model.
The Power Behind Enterprise EHR Software for Large Healthcare Systems
Enterprise EHR boosts scalability, interoperability, and governance for large healthcare systems.
Caught in the Middle: Unraveling Payer-Provider Blame in United States Healthcare
The real issue isn’t one payer, one policy or one bad actor. It’s a deeply fragmented system built on competing incentives, misaligned responsibilities and layers of administrative friction.
Telehealth Fraud & Compliance: Preventing ‘Pill Mills’ While Ensuring Access to Care
The future of telehealth is trust, combined with patient education. As the market matures, all parties — providers, regulators, and platforms — must collaborate to sustain that trust.
AI: A Good Tool to Combat Bad Actors in Healthcare
AI can be a highly effective tool for plans aiming to reduce fraud, waste and abuse, but only if it is combined with investigative intelligence.
“Friendly” PC Models: Key Contractual and Compliance Considerations
Business and compliance considerations for MSOs and PCs, the contractual structure, and general recommendations for establishing a model that runs efficiently and mitigates levels of risk
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Inside an Automated Healthcare Practice: Redesigning Care Around People, Not Paperwork
By reducing administrative burden and redesigning workflows around human needs, it creates space for what matters most: connection between clinicians and patients.
Mental Health Fraud Schemes: How to Protect Your Plan
By being aware of the latest schemes, health plan leaders can ensure their members have appropriate access to care while preventing bad actors from exploiting telehealth policies established during the pandemic.
Coordination of Benefits: An Overlooked Pillar of Medicaid Programs
Coordination of benefits is a critical pillar of the Medicaid program as it ensures the efficient use of resources, prevents overutilization, promotes equity in resource distribution, mitigates fraud and abuse, contributes to program longevity and ultimately enhances healthcare access for beneficiaries.
How Emblem Health’s CFO is looking at reforming prior authorization
Emblem Health’ s chief financial officer knows that prior authorization — where patients have to get advance clearance for a procedure from their insurance companies through their providers — can be frustrating. But in an interview at the Total Health conference organized by Reuters Events in Chicago on Thursday, she rejected the notion that the […]
A looming reckoning: Medicare Advantage audits will spike as feds scope out Covid-19 fraud
Seniors’ demand for Medicare Advantage plans shows no signs of slowing down any time soon, and that means CMS is likely to continue accelerating its FWA audits of MA plans, particularly given the prevalence of Covid-19-related fraud.
The Power of Real World Data to Study Women’s Health at Scale
Veradigm examines key clinical trends, comorbidity profiles, and treatment trends across adolescence, reproductive years, and peri-/post-menopause. Download it today!
How payment integrity tools can help payers to tackle fraud, waste and abuse
Although telehealth offers many benefits for patients, it introduces operational complexities for providers and creates legitimate concerns about fraud, waste and abuse for payers.
New JAMA study finds administrative complexity as the single-largest source of wasteful spending
A new study evaluating waste in the U.S. healthcare system identified six areas of wasteful spending and how cost curtailment efforts are ongoing there.