Category: Blog

How AI and Automation are Revolutionizing Payment Integrity in Healthcare

How AI and Automation are Revolutionizing Payment Integrity in Healthcare

Healthcare payment integrity is a crucial aspect of efficient claims processing, and its improvement can significantly reduce costs and improve patient care. Healthcare costs continue to climb, burdening patients, providers, and insurers alike. A significant driver of this issue is the inefficiency of healthcare administration, particularly in claims processing. Despite standardized claim formats, outdated systems […]
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claim denial management

Claim Denial Management: A Comprehensive Guide

Claim denials are a common challenge for healthcare organizations, often leading to significant revenue loss. While it’s impossible to eliminate denials entirely, proactive Claim denial management can significantly reduce their impact. Industry standards for claim denials are lacking, making it difficult to track and analyze denial trends. Each payer has its own unique policies and […]
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Medicare Telehealth Policy Changes: What Patients and Providers Need to Know

Medicare Telehealth Policy Changes: What Patients and Providers Need to Know

Medicare Telehealth Policy Changes are set to reshape the landscape of telehealth services. As the COVID-19 public health emergency ends, Medicare will revert to pre-pandemic policies, imposing stricter rules for telehealth services starting January 1, 2025, unless Congress intervenes. Key changes include: Geographic Restrictions: Patients must generally live in a health professional shortage area, a […]
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The Role of External Coding Audits in Healthcare

The Role of External Coding Audits in Healthcare

The constant updates in medical codes and evolving payer regulations, healthcare providers are increasingly turning to external coding audits. This blog post explores the importance of external coding audits, benefits, and how they support the healthcare industry in minimizing compliance risks, improving revenue integrity, and enhancing operational efficiency. 1. What Is an External Coding Audit? […]
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CMS Finalizes MPFS with 2.9% Medicare Physician Pay Cuts

CMS Finalizes MPFS with 2.9% Medicare Physician Pay Cuts

The Centers for Medicare & Medicaid Services (CMS) has finalized its 2025 Medicare Physician Fee Schedule, which includes a 2.9% Medicare Physician Pay Cuts to physician payments. This decision, despite opposition from major industry groups, will impact healthcare providers and potentially patient access to care. The rule also includes several positive provisions, such as expanded […]
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 DSMT and MNT: A Comprehensive Guide for Healthcare Providers

As diabetes prevalence increases, the importance of diabetes self-management training (DSMT) and medical nutrition therapy (MNT) becomes undeniable. To empower patients, optimize health outcomes, and ensure sustainable access, healthcare systems must integrate DSMT and MNT into diabetes care protocols. This article highlights the critical role of registered dietitians (RDs) and nutrition professionals in providing these […]
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Modifier 26 and Modifier TC for Accurate Healthcare Billing

Modifier 26 and Modifier TC for Accurate Healthcare Billing

In the realm of healthcare billing and coding, modifiers are crucial tools used to provide additional context and specificity to procedure and diagnosis codes. These modifiers help healthcare providers accurately communicate the nature of services rendered to payers. Two commonly used modifiers, Modifiers 26 and Modifier TC, play significant roles in clarifying billing practices and […]
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Optimizing Debridement Coding: Tips for Accurate Claims and Payments

Optimizing Debridement Coding: Tips for Accurate Claims and Payments

The growing U.S. wound care market, fueled by an aging population and rising rates of chronic conditions, presents significant opportunities for healthcare providers. Accurate debridement coding is essential to maximize reimbursement and optimize patient care. Pressure injuries alone affect around 2.5 million Americans each year, leading to more than 60,000 deaths and costing between $9.1 […]
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How to Use Modifiers 59 and X[ESPU] to Maximize Reimbursement

How to Use Modifiers 59 and X[ESPU] to Maximize Reimbursement

When you bill for distinct, separate procedures, it’s crucial to know which modifiers will ensure full payment for each service. Modifier 59, “Distinct Procedural Service,” acts as a universal tool to unbundle procedures that are typically included in a larger procedure or “bundled” together. This modifier signals to the payer that specific circumstances justify separate […]
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New CMS Rule: Medicare Appeals Process for Reclassified Patients

New CMS Rule: Medicare Appeals Process for Reclassified Patients

On October 11th, the Centers for Medicare & Medicaid Services (CMS) issued a final rule establishing a new Medicare appeals process for Medicare beneficiaries who are initially admitted to a hospital as inpatients but later reclassified as outpatients receiving observation services. This rule is a result of the class-action lawsuit that sought to establish appeal […]
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