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Industry News from AppriseMD

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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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Compliance with CMS 4201-F pie chart

Medicare Advantage Organization Non-Compliance with The Two-Midnight Rule Findings

AppriseMD hospital utilization review data for the first two months of 2024 shows that Medicare Advantage Organizations (MAOs) are denying claims that would have been approved under Traditional Medicare. BACKGROUND MAOs must adhere to the same guidelines as Traditional Medicare as per the Center for Medicare and Medicaid Services’ (CMS) 2024 rule 4201-F. MAOs can […]
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Medicare Advantage 2023 enrollment by payer

Payer Claim Denials & Medicare Advantage Organizations Market Share

Medicare Advantage (MA) plans traditionally implement more restrictive medical necessity requirements than Traditional Medicare. They also produce a higher denial rate than all other payer categories combined, according to Crowe.  This leaves hospitals investing more time and resources into ensuring appropriate reimbursement. MA plans already account for a generous portion of Medicare plans in the US, and […]
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Additional News to Note

Legislation

A new California law went into effect Jan. 1 that prohibits payers from making coverage decisions based solely on artificial intelligence algorithms.

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Legislation

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

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Outlook

Learn more about what hospital CEOs can expect from CMS in 2025 here.

AHA

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

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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.

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