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Industry News from AppriseMD

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payment policy for hospitals balancing cost and care

Understanding Aetna’s New Level of Severity Inpatient Payment Policy

Hospitals and health systems across the country are preparing for a significant shift in how Aetna reimburses certain inpatient stays. Aetna’s Level of Severity Inpatient Payment Policy, which went into effect January 1, 2026, (updated from the original effective date of November 15, 2025) introduced a new framework for evaluating and reimbursing urgent or emerging […]
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AppriseMD physician advisor

Are Rising Healthcare Costs And Increasing Denial Rates Impacting Your Hospital’s Revenue?

Exploring effective denial management strategies makes a significant difference for a hospital’s bottom line. One key component that hospitals and health systems should no longer be overlooking is specialized physician advisors who can transform revenue cycles and ensure higher quality care while safeguarding revenue streams. The latest and best solutions for improving revenue cycle and […]
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Physician Advisors: Specialists for your Utilization Management Team

Physician Advisors: Specialists For Your Utilization Management Team

Physicians specialize in medicine for various reasons, though primarily to improve patient outcomes by providing more focused care and reducing medical errors. This also allows physicians to see more patients in a period, making them more efficient at delivering quality care. The concept of specialization in healthcare is not new, however it is not always […]
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Hospitals should file a complaint when the Medicare Advantage (MA) plans do not follow the Two-Midnight rule

Hospitals Should File A Complaint When Medicare Advantage Plans Do Not Follow Two-Midnight Rule

An American College of Physician Advisors’ (ACPA) recent report concurs with earlier data from AppriseMD that many Medicare Advantage Organizations (MAOs) are not complying with the guidelines that the Centers for Medicare and Medicaid Services established under rule 4201-F. In its News to Note from July 20241, the ACPA looked at whether all of the […]
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the impact of weekend utilization review

The Financial Impact of Weekend Utilization Review

Missing adequate weekend assessments exposes up to 29% of hospital days to potential payment issues. Physicians consider many factors during the complex clinical judgement used in determining a hospital admission. Many hospitals operate with reduced staffing on the weekends, and this can have a significant impact on reimbursement when factoring that weekends encompass approximately 105 […]
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AI in healthcare claims

Payers, Artificial Intelligence and Revenue Cycle

As the use of artificial intelligence (AI) in healthcare claims management widens, the importance of careful oversight is needed. Any use of automation for claim denials should be scrutinized by providers to ensure the denial is appropriate. A recent Healthleaders report asked a key question all revenue cycle managers must consider: What is the balance […]
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Additional News to Note

Legislation

A law restricting health insurance companies from using AI to alter provider codes that otherwise change the provider’s clinical judgment was introduced in New Hampshire. 

Read about the proposed legislation

Texas joins California in looking at how payers are using AI to deny claims. 

Read about the bill 

Outlook

Medicare Advantage enrollment is expected to decrease in 2026.

While the MA market share grew in 2025, it was not as much as anticipated. The lower than projected enrollment growth stems from several factors, one of which includes provider pushbacks. This is not surprising given the prevalence of claim denials, prior authorization requirements and reimbursement challenges that have plagued hospitals and physicians.

Read more about MA enrollment expectations in 2026.

 

AHA & AMA

AppriseMD applauds the American Medical Association for the launch of the Center for Digital Health and AI, "a new endeavor created to put physicians at the center of shaping, guiding, and implementing technologies transforming medicine."

Read announcement 


The American Hospital Association (AHA) commended CMS for initiating steps to expand oversight of the 2026 Medicare Advantage (MA) plans last month. 

Read statement 


Download AHA fact sheet "Improving Access to Care for MA Beneficiaries."


According to the AHA, hospitals continue to encounter obstacles from insurer policies, negatively impacting patient care and costs.

Read AHA article 

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