Claims reimbursement
Providers rely on payer reimbursement to cover the costs of providing healthcare services. Without timely and complete reimbursement, providers may struggle to maintain operations. Effective claims management helps to reduce errors and minimize fraud risk while streamlining the reimbursement process to decrease denials.
Top Stories
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News
30 Oct 2025
Insurers point to provider misuse of surprise billing arbitration
A new report from AHIP and BCBSA shows providers submitting high volumes of ineligible claims, as payers and providers continue to place blame for federal IDR hiccups. Continue Reading
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22 Oct 2025
R1 launches a revenue 'operating system' for end-to-end coverage
R1 announced the launch of the Phare Operating System, which utilizes AI agents to orchestrate automated revenue cycle management, spanning from patient access to denials management. Continue Reading
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10 Jul 2020
TX Hospitals to Receive $1B Boost in Medicaid Reimbursement
The state’s governor secured the Medicaid reimbursement for the Uniform Hospital Rate Increase Program, which aims to reduce the Medicaid shortfall for Texas hospitals. Continue Reading
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09 Jul 2020
98% of Eligible Clinicians Avoided a MIPS Penalty in 2018
Nearly all eligible clinicians avoiding a MIPS penalty earned a positive adjustment, with a higher portion also receiving special scoring for MIPS APM participation, CMS reports. Continue Reading
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08 Jul 2020
Telehealth Billing Increased 8,336% from April 2019 to April 2020
Providers increasingly engaged with telehealth billing as the pandemic took hold, with telehealth claim lines growing from 0.15% of medical claim lines in April 2019 to 13.00% in April 2020. Continue Reading
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06 Jul 2020
Key COVID-19 Claim Denial Trends Arising from the CARES Act
Medical billing provisions in the CARES Act have led to an uptick in mispayments and claim denials that will need to be addressed by providers to ensure accurate reimbursement and compliant patient billing. Continue Reading
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03 Jul 2020
HHS Reduces Medicare Appeals Backlog by 43%
HHS is ahead of schedule for eliminating the Medicare appeals backlog, with a recent 43% reduction leaving just under 243K appeals still pending by the end of the second quarter of 2020. Continue Reading
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01 Jul 2020
AHA Projects $323B in COVID-19 Hospital Financial Losses in 2020
Updated data from the AHA indicates that hospital financial losses will grow by a minimum of $120.5B from July 2020 through December 2020, adding to the $202.6B in losses from earlier this year. Continue Reading
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30 Jun 2020
Primary Care Practices to Take $15B Hit from Early COVID-19 Response
A new study estimates that primary care practices will lose over $65K in revenue per full-time physician after drastic declines in office visits and payments from March to May 2020. Continue Reading
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29 Jun 2020
New CPT Code Expands COVID-19 Coding, Billing to Antigen Tests
The AMA’s new Category I CPT code will allow for COVID-19 coding and billing of antigen tests performed on patients suspected of being infected by the novel coronavirus. Continue Reading
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26 Jun 2020
Prior Authorization Burden Continues to Rise, Physicians Report
86% of practicing physicians said the prior authorization burden increased over the last five years despite efforts from the AMA and policymakers to streamline the process. Continue Reading
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22 Jun 2020
FAH Wants More Time, Lower Rates on Advance Medicare Payments
Hospitals should have at least until 2021 to repay Medicare payments advanced by CMS during the COVID-19 pandemic, the group says. Continue Reading
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16 Jun 2020
Skilled Nursing Facilities Facing a Financial Crisis from COVID-19
Deemed the epicenter of COVID-19 deaths by many, skilled nursing facilities and other nursing home providers are now on the verge of collapsing without financial help, industry leaders say. Continue Reading
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11 Jun 2020
Providers Want Equal Telehealth Reimbursement Beyond COVID-19
With telehealth reimbursement flexibilities set to expire following the public health emergency period, providers are calling on HHS and policymakers to continue payment parity beyond COVID-19. Continue Reading
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08 Jun 2020
AHA Asks for Another $50B in Coronavirus Relief for Hospitals
The association urged HHS to distribute $30B in additional coronavirus to relief to all hospitals, as well as special disbursements to hospitals in COVID-19 hotspots and those that treat more Medicaid patients. Continue Reading
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05 Jun 2020
Appeals Court Nixes Fraud Case Against Baylor Scott & White Health
The court affirmed a district court’s decision to dismiss a False Claims Act lawsuit alleging the Texas hospital system of billing Medicare using inflated codes. Continue Reading
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03 Jun 2020
Hospital Volume Recovery Sluggish Despite More Outpatient Visits
Driven by an uptick in outpatient visits, hospital volume is rebounding from the COVID-19 pandemic. But volumes are still well off 2019 levels as patients continue to avoid inpatient and ED care. Continue Reading
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02 Jun 2020
Out-of-Network Bills Common for Some Pathologists, Other Specialists
Less than half of specialists bill out of network, but some of those who engage in out-of-network billing do so more than 90 percent of the time, new research shows. Continue Reading
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01 Jun 2020
CMS Issues COVID-19 Billing Updates for Hospitals, Alternate Sites
New COVID-19 billing guidance from CMS clarifies reimbursement and coding policies for hospitals treating COVID-19 patients and alternate care sites created by hospitals during the pandemic. Continue Reading
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29 May 2020
HHS Gives $4.9B to Skilled Nursing Facilities Impacted by COVID-19
The funds will help skilled nursing facilities to offset significant expenses and lost revenues attributable to COVID-19, but more is needed to support long-term care, providers said. Continue Reading
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28 May 2020
1 in 5 Hospital Execs Expect Revenue Declines of Over 30% in 2020
Nearly all hospital executives in a recent survey anticipate their revenues to be lower at the end of 2020 as a result of COVID-19, but the pandemic could also spur more telehealth and M&A. Continue Reading
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14 May 2020
Hospital Payer Mix Influenced Size of Coronavirus Relief Funding
The size of coronavirus relief funding depended largely on a hospital’s payer mix, with hospitals relying on private payer revenue receiving 2x as much, KFF reported. Continue Reading
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14 May 2020
Small Practices Benefit Less from Medicare’s Care Management Codes
Large practices and practices other than a beneficiary’s assigned PCP are using Medicare’s care management codes more frequently, suggesting that the codes are not supporting primary care as expected. Continue Reading
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04 May 2020
HHS Gives $22B to Hospitals in COVID-19 Hotspots, Rural Areas
Rural hospitals and hospitals with high COVID-19 admissions will be receiving emergency payments from HHS to combat the novel coronavirus. Continue Reading
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27 Apr 2020
CMS Ends Advance Payments for Physicians, Other Part B Providers
The federal agency is also reevaluating the amounts paid under the Accelerated Payment Program, a similar advance payment initiative for hospitals during emergencies. Continue Reading
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27 Apr 2020
Coronavirus Healthcare Costs Could Total Up To $654B, Study Finds
A new study shows that coronavirus healthcare costs could tally up to $654B if 80% of the population becomes infected under herd immunity and other containment strategies. Continue Reading
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27 Apr 2020
Mitigating the Risk of Uncompensated Care to the Revenue Cycle
Uncompensated care remains a growing problem for healthcare providers, but scanning the entire revenue cycle can help find missing coverage quickly. Continue Reading
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24 Apr 2020
Studies Examine Surprise Billing for Ambulance Rides, ASC Visits
71% of ground and air ambulance rides involved potential surprising billing, while a separate study found a significantly lower rate among ASC visits. Continue Reading
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Answer
17 Apr 2020
What Providers Need to Know About COVID-19 Coding and Billing
The healthcare system is facing an unprecedented crisis, but accurate COVID-19 coding and billing can help providers weather the storm and prepare for future outbreaks. Continue Reading
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13 Apr 2020
3 Key Activities to Prevent Denied Claims in 2020
A three-pronged approach to denials management can help healthcare providers reduce lost revenue over the coming year. Continue Reading
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08 Apr 2020
CMS Pays Out $34B in Advance Medicare Reimbursement to Providers
The advance Medicare reimbursement will aid providers struggling to stay afloat during the COVID-19 crisis but will need to be paid back to CMS. Continue Reading
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08 Apr 2020
Hospital Reimbursement for Uninsured COVID-19 Cases May Total $42B
Hospital reimbursement for uninsured COVID-19 hospitalizations will range from nearly $14B to $42B, accounting for a significant portion of the $100B slated for hospitals in the CARES Act. Continue Reading
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06 Apr 2020
Hospital Stimulus Funds to Pay for Uninsured COVID-19 Treatment
Part of the $100 billion in hospital stimulus funds will go to paying providers Medicare rates for COVID-19 treatment for uninsured patients, the HHS Secretary said Friday. Continue Reading
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02 Apr 2020
AHA Asks for an Immediate $25K Per Hospital Bed to Combat COVID-19
Hospitals in COVID-19 hot spots would get $30k per bed from their MAC, according to the AHA’s plan to immediately distribute funds from the coronavirus stimulus package. Continue Reading
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30 Mar 2020
CMS Offers Upfront Medicare Reimbursement During COVID-19 Pandemic
The agency announced the expansion of its Accelerated and Advanced Payment Program for providers receiving Medicare reimbursement amidst the COVID-19 pandemic. Continue Reading
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30 Mar 2020
Hospitals to Lose $1K Per COVID-19 Case Despite Medicare Rate Bump
Even with the 20% Medicare rate increase in the stimulus package, hospitals are set to lose about $1,200 per COVID-19 hospitalization, a new analysis shows. Continue Reading
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24 Mar 2020
Documentation to Ease Medical Billing Issues Due to COVID-19
A healthcare lawyer advises providers to thoroughly document care delivery to prevent medical billing and payment issues likely to arise from the COVID-19 pandemic. Continue Reading
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16 Mar 2020
MedPAC Suggests No Medicare Payment Increase for Physicians
The commission also recommended in its annual March report a 2% increase in Medicare payment for hospital services. Continue Reading
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16 Mar 2020
CMS Releases Medicare Reimbursement Details for COVID-19 Tests
Medicare reimbursement for COVID-19 tests will be about $36 for the CDC test and $51 for those created in house or by other entities. Continue Reading
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11 Mar 2020
No Reimbursement Impedes Social Determinants of Health Progress
A lack of direct reimbursement was the top factor standing in the way of social determinants of health progress, followed by inability to demonstrate ROI, a survey shows. Continue Reading
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04 Mar 2020
42% of Anesthesiologists Had Contracts Terminated in Last 6 Months
A survey of anesthesiologists shows that insurers are abruptly terminating physician contracts, forcing many of the specialists out of network. Continue Reading
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02 Mar 2020
Number of Medicare-Dependent Hospitals Falls by 28%
The number of Medicare-dependent hospitals (MDHs) that received additional payments also declined by 15% from 2011 to 2017, GAO found. Continue Reading
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24 Feb 2020
Inpatient No Longer King as Hospital Outpatient Revenue Grows
The gap between inpatient and hospital outpatient revenue narrowed, with outpatient dollars accounting for nearly half of total hospital revenue by 2018, a new report shows. Continue Reading
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20 Feb 2020
Claims Reimbursement Changes Notably Reduce Low-Value Care
Recommendations alone may be insufficient for reducing low-value care services, but have a greater impact when reinforced by changes to claims reimbursement. Continue Reading
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20 Feb 2020
Patient-Driven Payment Model Reimbursement Exceeds CMS Prediction
After the Patient-Driven Payment Model closed its first billing cycle, rates exceeded CMS’ predictions for skilled nursing facilities. Continue Reading
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19 Feb 2020
Medicare Payments Unfair to Providers Treating Vulnerable Patients
Providers, hospitals, and Medicare Advantage plans treating the most vulnerable populations are at risk for inequitable Medicare payments given the program’s current payment system. Continue Reading
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18 Feb 2020
Emergency Medicine’s Ongoing Battle for Equitable Reimbursement
Emergency departments have a responsibility to treat all patients, but many fail to understand the business challenges of operating under this unique model. Continue Reading
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13 Feb 2020
20% of Elective Surgery Patients Receive a Surprise Medical Bill
A substantial portion of operations ended in an out-of-network billing, leading to potential surprise medical bills totaling thousands of dollars, a study found. Continue Reading
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10 Feb 2020
5 Key Ways to Ensure Hospital Compliance Program Consistency
Implementing a consistent hospital compliance program is key to cultivating a culture of compliance that minimizes revenue risks, so providers can focus on high-value care. Continue Reading
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10 Feb 2020
Hospitals Closed 2019 with An Uptick in Volume, Patient Revenue
Hospitals saw a boost in hospital profitability in December 2019, with volume and patient revenue rising despite a slight increase in supply expense. Continue Reading
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04 Feb 2020
Overcoming Growing Pains Through Effective Hospital Compliance
Hospitals and health systems are increasingly expanding into the ambulatory space. While positive, this growth does necessitate a shift in hospital compliance. Continue Reading
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30 Jan 2020
CO Healthcare Costs Keep Climbing Due to Hospital Cost-Shifting
A new report from the state shows that hospital cost-shifting has continued to increase healthcare costs despite regulations intended to stymie the practice. Continue Reading
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29 Jan 2020
Medicare Overpaid Surgeons by $2.6B for Postoperative Care
A study shows that Medicare reimbursed surgeons for postoperative care visits for nearly all minor surgical procedures despite only 4% resulting in postoperative care. Continue Reading
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27 Jan 2020
3 Components of a Proactive Hospital Compliance Program
Internal and external audits, as well as education and training, are all ways hospitals can install a proactive compliance program. Continue Reading
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24 Jan 2020
Prior Authorization Costs Rise as Electronic Adoption Remains Low
According to CAQH, manual prior authorization costs increased by $4.31 from 2018 to 2019, making it the costliest administrative transaction for providers. Continue Reading
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21 Jan 2020
American College of Physicians Endorses Single-Payer System
The second-largest physician group backed a single-payer system or public option in a recent policy plan. Continue Reading
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21 Jan 2020
MedPAC Recommends 3.3% Hospital Payment Boost, No Change for Docs
The hospital payment boost would fall short of the current law, but ensure hospitals are paid for the quality of care delivered, MedPAC stated. Continue Reading
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20 Jan 2020
Strategies to Mitigate Shrinking Reimbursement in Emergency Medicine
Emergency departments are under intense pressure to do more with less, and drilling down into clinical and operational data can provide opportunities to offset decreasing revenues Continue Reading
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17 Dec 2019
Out-of-Network Billing for Hospital Care Boosts Spending by $40B
Out-of-network billing was common among hospital-based anesthesiologists, pathologists, radiologists, and assistant surgeons, and these providers were able to negotiate higher in-network rates as a result. Continue Reading
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02 Dec 2019
3 Ways to Build an Effective Hospital Compliance Program
Communication and education are critical to building hospital compliance programs in a value-based world, and technology holds the key to future success. Continue Reading
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25 Nov 2019
6 Ways to Accelerate Physician Reimbursement at Radiology Practices
Radiology practices face challenges to physician reimbursements but improve inefficiencies in more than a handful of ways. Continue Reading
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18 Nov 2019
Automating Revenue Cycle Management Improves Patient Experience
The right revenue cycle management technology can create a transparent, seamless patient experience, which benefits the bottom line. Continue Reading
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12 Nov 2019
Providers Ready for AI Clinical Documentation Improvement Tools
88% of providers are eager to implement clinical document improvement technology that leverages AI, and 93% believe the systems can streamline document creation. Continue Reading
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28 Oct 2019
Federal Hospital Reimbursement to Take $252B Hit by 2029
A recent study found that 12 pieces of legislation and regulatory changes are estimated to decrease federal hospital reimbursement from 2010 to 2029. Continue Reading
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14 Oct 2019
Prior Authorizations, Quality Payment Program Burden Practices
86% of medical group practices in an MGMA report said regulatory burden rose in the last year, with prior authorizations and the Quality Payment Program adding to that burden. Continue Reading
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14 Oct 2019
3 Coding Compliance Strategies to Improve Reimbursement, Quality
Improving clinical documentation quality, leveraging technology, and educating providers are key ways hospitals improve coding compliance in a value-based world. Continue Reading
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07 Oct 2019
Developing a Hospital Claim Validation Strategy to Prevent Denials
A comprehensive hospital claim validation strategy that prevents denials and improves efficiencies hinges on the right blend of retrospective and pre-bill reviews. Continue Reading
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17 Sep 2019
Hospitals Retain 91% of Profit from Physician-Administered Drugs
Hospital keep a greater share of the gross profit margin on physician-administered drugs, indicating a need to level the playing field for physician practices, according to some experts. Continue Reading
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20 Aug 2019
6 Challenges of End-to-End Automation for Prior Authorizations
Data inconsistency, limited vendor solutions, and lack of interoperability are among the top barriers preventing prior authorization automation, CAQH reports. Continue Reading
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06 Jun 2019
How Advocate Aurora Health Streamlined Prior Authorizations
The health system reduced the burden of prior authorizations while upping medication adherence by automating the process in the EHR and creating an authorization team. Continue Reading
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11 Mar 2019
Why Do We Need Artificial Intelligence in Healthcare?
Artificial intelligence in healthcare can lead to immediate gains by reducing inefficiencies in the revenue cycle. Continue Reading
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07 Jan 2019
Maximize Hospital Revenue with a Holistic Insurance Discovery Strategy
Looking beyond self-pay accounts for insurance discovery and identifying valuable coverage information helps both recover—and increase—hospital revenue. Continue Reading
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10 Dec 2018
Getting the Medicare Cost Report Right the First Time
Data analytics can help hospitals submit a complete and accurate Medicare cost report in the face of constant rule changes and an uptick in audits. Continue Reading
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03 Dec 2018
Healthcare Payment Integrity is Vital to Maximizing Reimbursements
Identifying underpayments or claiming supplemental reimbursement is resource-intensive, but a healthcare payment integrity solution can recoup lost revenue. Continue Reading
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17 Sep 2018
How Automating Payer Enrollment Reduces Time to Reimbursement
A lack of automation for payer enrollment and other claims management processes is delaying reimbursement, but outsourcing payer enrollment can reduce the wait. Continue Reading
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10 Sep 2018
RCCH Uses Predictive Analytics to Boost Claim Denials Management
A Tennessee-based healthcare organization uses predictive analytics to identify high-value denials and add accountability to their claim denials management strategy. Continue Reading
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10 Sep 2018
Using Payer Enrollment to Jumpstart Revenue Cycle Optimization
Outsourcing payer enrollment services helps healthcare organizations streamline the enrollment process, navigate payer rules, and monitor revalidation. Continue Reading
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04 Sep 2018
Artificial Intelligence Ensures Payer, Provider Pay Covers Costs
Gateway Health Plan is using artificial intelligence to improve its risk adjustment programs, which ensure the payer and its providers receive reimbursement that covers a patient’s total cost of care. Continue Reading
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16 Jul 2018
Overcoming the Top Challenges of Claims Denial Management Audits
Increasing efficiency and improving revenue are top priorities for health care providers with a big focus on improving prior authorizations and eligibility before an episode of care. Continue Reading
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23 Oct 2017
4 Strategies for Merit-Based Incentive Payment System Success
Eligible clinicians can prevent a Merit-Based Incentive Payment System penalty in 2017 by selecting the right measures and engaging their vendors and physicians. Continue Reading
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06 Oct 2017
Maximizing Revenue Through Clinical Documentation Improvement
A strong revenue cycle rests on accurate, timely data. Clinical documentation improvement offers an opportunity to improve coding and maximize reimbursement. Continue Reading
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28 Sep 2017
Cancer Care Costs 60% Higher at Hospitals Vs Independent Orgs
Cancer care costs for chemotherapy and physician visits are significantly less at independent community oncology practices, a study showed. Continue Reading
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11 Aug 2017
Key Strategies for Succeeding with Healthcare Bundled Payments
In order to succeed with healthcare bundled payments, providers must engage post-acute care providers, leverage data analytics, and improve their patient engagement strategies. Continue Reading
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20 Jul 2017
3 Challenges Providers Face with Healthcare Bundled Payments
The top challenges of healthcare bundled payments include achieving scale, leveraging post-acute care resources, and managing uncontrollable costs. Continue Reading
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09 Jun 2017
The Difference Between Medicare and Medicaid Reimbursement
Medicare and Medicaid reimbursement models vary according to federal and state regulations, but both are striving to embrace value-based reimbursement. Continue Reading
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11 May 2017
3 Best Practices for Hospital Claim Denials Management
Implementing claim denials management best practices is key to ensuring hospitals maximize claims reimbursement revenue and prevent denials. Continue Reading
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10 Mar 2017
Top 4 Claims Denial Management Challenges Impacting Revenue
Common claims denial management obstacles for providers include quantifying denial rates, using manual processes, receiving preventable denials, and appealing claims. Continue Reading
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04 Nov 2016
How to Maximize Revenue with Improved Claims Denials Management
Enhancing claim denials management strategies can help providers recoup lost healthcare revenue and maximize reimbursements. Continue Reading
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02 Aug 2016
4 Medical Billing Issues Affecting Healthcare Revenue Cycle
Addressing these four common medical billing challenges can have a positive impact on the healthcare revenue cycle. Continue Reading
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15 Apr 2016
Defining the Top 10 Terms of Healthcare Revenue Cycle Management
MACRA, MIPS, accountable care, and supply chain management are among the top terms used by healthcare revenue cycle pros. Continue Reading
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12 Apr 2016
Key Ways to Improve Claims Management and Reimbursement in the Healthcare Revenue Cycle
To keep pace with changes to healthcare reimbursement, hospitals and healthcare organization need to reduce inefficiency in revenue cycle management. Continue Reading
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21 Sep 2015
3 Strategies to Improve Healthcare Supply Chain Management
The evolution and progression of supply chain and reimbursement tactics and procedures within the healthcare industry serves as a keen present focal point. Continue Reading
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30 Mar 2015
Quantify Denial Rates for Smooth Revenue Cycle Management
The ability to swiftly and economically scrub claims and quantify denial rates is critical to ensure smooth revenue cycle management. Continue Reading
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09 Mar 2015
What Steps Comprise the Life Cycle of a Medical Claim?
It is important to recognize and distinguish each stage from the other within the total life cycle of a medical claim to decrease errors and cost. Continue Reading
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04 Nov 2014
Examining Differences Between Medicare, Medicaid Reimbursement
While Medicare and Medicaid are similar programs, there are different challenges when it comes to reimbursement. Continue Reading