ERISA Recovery’s Post

AI cannot be used to deny #healthcare coverage, feds clarify to insurers CMS worries AI could wrongfully deny care for those on Medicare Advantage plans. by Beth Mole #Healthinsurance companies cannot use #algorithms or #artificialintelligence to determine care or deny coverage to members on Medicare Advantage plans, the Centers for #Medicare & #Medicaid Services (CMS) clarified in a memo sent to all #MedicareAdvantageinsurers (https://lnkd.in/ebB8XHfQ). The memo—formatted like an FAQ on #MedicareAdvantage (MA) plan rules—comes just months after patients filed lawsuits claiming that UnitedHealth and Humana have been using a deeply flawed, AI-powered tool to deny care to elderly patients (https://lnkd.in/eDNtTBp9) on MA plans. The lawsuits, which seek class-action status, center on the same #AItool, called nH Predict, used by both insurers and developed by NaviHealth, a UnitedHealth subsidiary. https://lnkd.in/ezpD8aaH

Quoting Susan J. Baumgaertel, MD FACP on what healthcare should be: “rich tapestry of human-centered care 🌤️  Physician-patient interactions should be mutually respected and valued 🌤️  Physician-patient relationships should be healing 🌤️  Training and experience matter 🌤️  Transparency and safety matter 🌤️  Trust matters” All of this!

😱 The DOJ is launching an investigation into UnitedHealth focusing on what seems to be their acquisition of providers and other hospital services (vertical integration). This is even more relevant given last week's Change Healthcare hack and its implications on the industry at large. Let’s see if this one sticks this time.🤞🏻 #congress #healthcare #healthpolicy #antitrust #verticalintegration

In today's world, you hear the terms "AI" and "technology" on a daily basis. While they are both critical in helping identify denied claims, human expertise is still required to complete a successful appeal. ERISA Recovery's proprietary process combines all forces to appeal denied claims on behalf of hospitals to get them the lost revenue they are owed. Check out our recent blog post to learn more: https://lnkd.in/g3cCqxWu #erisa #erisarecovery #erisaappeals #revenuecycle #revenuecyclemanagement #rcm #healthcarefinance #healthit #healthcareit #hospitalfinance #hospitalmanagement #denials #claimdenials #denialmanagement #denialsmanagement #healthcare #healthtech

Payers invest heavily in maintaining accurate provider networks, yet often face the challenge of "ghost networks." These outdated or incorrect directories frustrate patients and risk legislative action. Key Insights - 1. Federal Legislation - Bi-partisan bills aim to mandate accurate provider directories for Medicare Advantage and private insurance plans. 2. State Actions - States like California and Illinois propose stringent regulations to combat ghost networks. 3. Increasing Momentum - Behavioral health care is the initial focus, but broader reforms are likely. 4. Proactive Measures - Payers should verify provider data every 90 days, ensure fast updates, and prepare for public accuracy audits. 5. Action Plan - Leverage technology, including AI, to improve data accuracy and compliance, enhancing member satisfaction. Questions to Consider - - How can payers best leverage technology to eliminate ghost networks? - What proactive steps can be taken to stay ahead of upcoming legislation? - How will improved provider directories impact patient care and satisfaction? #Healthcare #DataAccuracy #PatientCare #Legislation #HealthTech

🌟Unlocking Efficiency in Healthcare Billing: Introducing Unthink MedEx! 🌟 Unthink MedEx is revolutionizing the way healthcare providers handle billing processes. As the founder of Unthink MedEx, I am thrilled to share how our pioneering medical e-billing company is poised to make a difference. 🚀 HIPAA (Health Insurance Portability and Accountability Act) is a critical piece of legislation that safeguards patient privacy and data security. Healthcare organizations and their business associates must adhere to strict guidelines when handling sensitive patient information. 🛡and Unthink is Committed to adhere with HIPPA Act. At Unthink MedEx, we are committed to simplifying the billing process for physicians, hospitals, and clinics. Say goodbye to paperwork headaches and administrative hassles! 💼 Our robust security measures prioritize complete privacy and confidentiality. Your patients' trust is our top priority. 🔒 By partnering with Unthink MedEx, you can focus more on what truly matters: patient care. Let us handle the billing intricacies while you make a difference in people's lives. 🌟 Join the revolution towards seamless, secure, and efficient billing processes. Connect with us at Unthink MedEx and be part of the transformation. 🤝 🔗 Mail us @ - Info@unthinkmedex.com 📞 Call us @ +91 6353-452348 🔍 Follow us on LinkedIn or Inbox us: Unthink MedEx #HealthcareBilling #MedicalBilling #HIPAACompliance #DataSecurity #PatientPrivacy #UnthinkMedEx #medicalbilling #healthcare #healthcareproofessional #financialaudit #healthcareforall #therapy #hospital #physicaltherapy #Denialclaims #medical #doctors #health #dorctorsonpinterest #medicine #nurse #claim #homecare #serviceprovider #billing #credentialing #patientsupport #medicalcoding #RCM #eligibilityverification

The good news is that over half of all clinical denial claims were eventually overturned within the last year. The bad news is that it took an average of 3 rounds of costly appeals, with providers often waiting up to 6 months after care was delivered to receive their payment. ERISA Recovery's advanced technology and team of experts helps providers get paid quickly. Our 3-3-3 process allows hospitals to start winning appeals (on the first attempt) within 3 weeks. Connect with us to learn more! #erisa #erisarecovery #erisaappeals #revenuecycle #revenuecyclemanagement #rcm #healthcarefinance #healthit #healthcareit #hospitalfinance #hospitalmanagement #denials #claimdenials #deniedclaims #denialmanagement #denialsmanagement #healthcare #healthtech

Is your practice facing #claimdenials due to overlooked #eligibility checks? Don’t let these small errors cause big revenue losses! Dive into our latest blog to uncover essential best practices for accurate #patienteligibilityverification. You can optimize your process, minimize denials, and protect your bottom line. Get all the insights here: https://lnkd.in/ggtTnkFE #QWay #QWayHealthCare #RCM #Healthcare #MedicalBilling #MedicalCoding #MedicalBillingServices #MedicalBillingCompany #RevenueCycleManagement

I wanted to take a moment to discuss a topic that might make some eyes glaze over, unless it is a specific personal or professional interest, and yet is an important example of how our healthcare system is both evolving and self-correcting (please see the MH article linked below). A significant development has emerged with the Centers for Medicare and Medicaid Services (CMS) finalizing a new rule, mandating government-sponsored health plans to respond to non-urgent pre-approval requests within seven days and to urgent ones within 72 hours. For those with less exposure to this topic, with managed plans the payer typically acts as a gatekeeper to more specialized and/or intensive (aka - expensive) care through a prior authorization process that is designed to assess medical need. With few rules or standards, it is common for extensive delays. This leads to physician and patient dissatisfaction and decreased clinical quality. This latest regulation is a substantial step towards modernizing the pre-approval process, with an expected saving of $15 billion for physician practices over the next decade and hopefully a drastic reduction in dissatisfaction. What I find to be most noteworthy is the support from insurers for this rule. Their backing suggests a shift in thinking. A shift that is likely impacted by the purposeful incentive alignment between providers and payers engineered by CMS through programs such as Medicare Advantage Stars. By design, these programs create standardized performance requirement that overlap both organizations types and is indicative of a move towards a more unified and systematic approach to care delivery. Now the focus will be on the technology investments that payers must make to meet this requirement and drive efficiency. I would like to also say that the potential for AI driven solutions from SAS and others to significantly exceed the proposed standards and turnaround times is very high, revolutionizing the entire process. Think turnaround times measured in hours or minutes rather than days! https://lnkd.in/ej6rwDHr #HealthcareInnovation #CMS #PriorAuthorization #HealthcareTechnology #HealthcarePolicy #InsuranceIndustry #MedicareAdvantage #Medicaid #CHIP #HealthcareImprovement

UnitedHealth's exploitation of an “emergency it created” raises serious ethical concerns.   The recent ransomware attack left an Oregon medical practice in dire straits, with UnitedHealth swooping in for an emergency takeover. This move, amidst the chaos caused by the weeks-long outage of UnitedHealth's Change Healthcare systems, seems opportunistic and callous. Instead of proactively assisting struggling #healthcareproviders, UnitedHealth has seemingly profited from the situation. This underscores the troubling power dynamics in #healthcare, where a massive insurer with extensive resources can pressure struggling providers into selling. It's a reminder of the need for transparency and accountability in the healthcare industry. Patients and providers alike deserve better than to be at the mercy of big insurance and its profit-driven interests. Learn more: https://lnkd.in/gdKxYC6a #healthinsurance