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.
Healthcare has solved for the hard part. The science, the surgery, the diagnosis: by global standards, we're exceptional. What we haven't solved for is what happens when the patient goes home.
Small practices play a critical role in healthcare delivery, but they cannot continue to absorb ever-increasing administrative demands without consequences.
New research from the Elevance Health Public Policy Institute finds that higher enrollment in Medicare Advantage may be linked to lower overall Medicare spending.
Chapter’s Series E round was led by Generation Investment Management, with participation from Fifth Down Capital, 8VC, Stripes, XYZ Venture Capital, Addition, Narya Capital, Susa Ventures and Maverick Ventures.
Over the past 15 years, financial and administrative barriers – most notably step therapy mandates and prior authorization requirements – have repeatedly forced patients through suboptimal or ineffective treatments before they can try another therapy, have tied the hands of healthcare professionals and patients alike. Now there's a possible solution.
A group of 131 hospitals has sued HHS over a CMS policy they say improperly reduces Medicare disproportionate share hospital (DSH) payments. The lawsuit is the latest in a decade-long legal battle over how the agency counts patient days and calculates payments for safety net hospitals.
Zelis highlights how employers, payers, and consumers are integrating digital tools to manage healthcare costs.
The specialty access and capacity crisis demands more than incremental fixes. It requires expanding virtual access and fundamentally rethinking how specialty care can be delivered.
For providers, the rules mean more control over monitoring and the chance to keep a larger share of reimbursement. For device companies, they create a chance to show measurable value and guide clinicians through a system that is shifting quickly.
The challenge for policymakers is balance: encouraging rigor without unintentionally weakening a program that now serves the majority of Medicare beneficiaries. Thoughtful rate calibration can determine whether this transition strengthens the program or strains it unnecessarily.
We have to cover medical nutrition therapy for those who need it most, including Medicare beneficiaries. Almost all commercial payers are already doing this - the government needs to catch up.
By reducing administrative burden and redesigning workflows around human needs, it creates space for what matters most: connection between clinicians and patients.
The American Medical Association is urging Congress to permanently extend Medicare’s pandemic-era telehealth flexibilities, warning that temporary extensions create uncertainty for patients and providers.
CMS’ new ACCESS model, slated to begin on July 1, aims to shift traditional Medicare fee-for-service toward value-based care by tying payments to patient outcomes and encouraging tech-enabled, preventive care. Experts say it could benefit digitally mature, value-focused providers first, but its overall success will hinge on clear metrics, better data sharing and sustained participation.
Here are three things providers should consider when it comes to Medicare.
Thirteen House Democrats introduced eight bills to rein in Medicare Advantage and bolster traditional Medicare.
Pluto Health is now working with Medicare, Medicaid and commercial plans like UnitedHealthcare, Aetna, Blue Cross Blue Shield, Ambetter and Cigna.