Category: Healthcare News

Electronic Claims Management

Electronic Claims Management: Overcoming ERA and PA Challenges

The U.S. healthcare industry continues its digital transformation, with providers and payers embracing electronic transactions to streamline revenue cycle management (RCM) processes. According to the CAQH Index, adoption of electronic claims management transactions—such as eligibility verification, claim submissions, and claim status inquiries—has reached or surpassed 80% for many transaction types. However, significant gaps remain in […]
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AI in Payment Integrity

What AI Can and Can’t Yet Do in Payment Integrity

The landscape of payment integrity, particularly within complex sectors like healthcare and financial services, is constantly evolving. As organizations grapple with escalating costs, intricate regulatory frameworks, and the persistent threat of fraud, waste, and abuse (FWA), Artificial Intelligence (AI) has emerged as a powerful ally. While AI’s capabilities in enhancing payment integrity are undeniably transformative, […]
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MIPS Penalties

MIPS Penalties Hit Small Practices Harder – RCM Solutions Key

When it comes to the Merit-based Incentive Payment System (MIPS), 2025 data reveals a striking disparity: small and rural medical practices were disproportionately penalized, facing significantly higher penalties than their larger, urban counterparts. While the vast majority of MIPS-eligible clinicians (86%) successfully avoided penalties this year, based on their 2023 data, those who did incur […]
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AI and HIPAA Compliance

AI Deployments and HIPAA Compliance in Healthcare

Navigating the intersection of AI deployments and HIPAA compliance presents significant challenges. Understanding AI and HIPAA the compliance landscape is crucial, and the foundational steps involve cultivating awareness and adhering to best practices to mitigate potential pitfalls. The integration of artificial intelligence within healthcare among practitioners has witnessed a notable surge in the past year, […]
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Reproductive Healthcare Data Privacy

Understanding the HIPAA Reproductive Healthcare Data Privacy Final Rule

The final rule issued by the Biden administration aimed to bolster the privacy of reproductive healthcare data under HIPAA, a significant move following the Supreme Court’s overturning. Health and Human Services (HHS) officials hoped this rule would alleviate the “chilling effect” on individuals seeking or providing legal reproductive healthcare, stemming from both legal challenges and […]
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FY 2026 IPPS Proposed Rule

IPPS Proposed Rule: Key Updates to HRRP, HAC, and VBP Programs

The Centers for Medicare & Medicaid Services (CMS) has unveiled its Fiscal Year (FY) 2026 IPPS Proposed Rule, which outlines significant updates to three key Medicare hospital quality initiatives: the Hospital-Acquired Condition (HAC) Reduction Program, the Hospital Readmissions Reduction Program (HRRP), and the Hospital Value-Based Purchasing (VBP) Program. These proposed changes, outlined in the IPPS […]
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Open-Source AI Medical Diagnostics

Open-Source AI Medical Diagnostics: Matches GPT-4 in Study

A groundbreaking study from Harvard Medical School has revealed that an Open-Source AI Medical Diagnostics model performed on par with GPT-4—one of the leading proprietary AI models—in diagnosing complex medical cases. Published in JAMA Health Forum, the findings suggest that physicians may soon have more options for integrating AI into clinical decision-making while maintaining greater […]
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FHIR-based ePA

Mastering CMS Rule 0057: Optimizing FHIR-Based ePA for Health Plans

The CMS Rule 0057 mandates that health plans develop and support FHIR-based APIs to facilitate FHIR-Based ePA. Whether this investment merely ensures compliance or unlocks broader benefits such as improved provider experience, enhanced efficiency, and streamlined operations depends on strategic planning and collaboration rather than cost alone To assist health plans in addressing these critical […]
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