Blog Posts by Author: Leigh Polk
4 Steps to Optimize the Prior Authorization Process
Prior authorization is a process used by insurance companies or health plans to confirm that certain medical services or procedures are necessary and appropriate before they are performed. This process helps ensure that patients receive appropriate care and that healthcare costs are managed effectively. While prior authorization can help prevent unnecessary medical treatments, it also comes with...
What The End of The PHE Means for Laboratory Providers
With the announcement from President Biden that his administration plans to end the COVID-19 Public Health Emergency (PHE) on May 11, 2023, many diagnostic providers are wondering how they will be impacted. CMS has published several provider-specific fact sheets about the PHE waivers and flexibilities, including which have been terminated, have been made permanent or will expire at the end of the...
No Surprises Act: 2023 Changes and Clarifications
Effective January 1, 2022, the No Surprises Act (NSA) established new federal protections against surprise medical bills and balance billing for services received from out-of-network providers.Since January 2022, CMS has published over 50 resources related to the Act, five of which were released as recently as December. In August 2022, CMS issued the final rules, entitled “Requirements Related to...
PAMA vs SALSA: 2023 Clinical Lab Fee Schedule Predictions
The Protecting Access to Medicare Act (PAMA) of 2014 set clinical laboratory fee schedule (CLFS) reimbursement rates on an unsustainable course of multiyear double-digit cuts. Under PAMA, the first set of Medicare CLFS payment rates resulted in cuts of 10% per year in 2018, 2019, and 2020. As a result of the COVID-19 public health emergency, no reductions were introduced in 2021 or 2022....
AUC Penalty Phase Delayed–Why Radiologists Need to Act Now, Not Later
The appropriate use criteria (AUC) program was established under The Protecting Access to Medicare Act (PAMA) of 2014 to ensure providers ordered the most appropriate advanced diagnostic imaging services for Medicare beneficiaries. Under the program, ordering providers will consult an electronic portal called a Clinical Decision Support Mechanism (CDSM) to ensure the established appropriate use...
No Surprises Act: Examining the Independent Dispute Resolution Process
The Final Rule implementing the No Surprises Act provides new guidance for the payor-provider independent dispute resolution (IDR) process. The Final Rule directs certified IDR entities to consider the qualifying payment amount as well as certain other specific factors when resolving out-of-network rate disputes and requires payors to be more transparent about changes to codes or modifiers that...
No Surprises Act: 4 Key Steps to Providing Good Faith Estimates
The No Surprises Act protects patients from receiving a surprise medical bill by prohibiting balance billing and requiring providers to provide good faith estimates (GFE) of services. A GFE should be provided to all patients who are uninsured and should include all services expected to be provided by both primary and co-providers.While the legislation went into effect on January 1, 2021, HHS did...
Optimizing Patient and Payor Payments with Patient Responsibility Estimator Tool
In 2021, the total US out-of-pocket healthcare patient spending increased by 10% from the previous year and is expected to continue to increase by 9.9% annually through 20231. An increase in a patient’s financial responsibility is a growing problem in healthcare and is driven by several factors including: Payors shifting a larger portion of the payment to patient responsibility, on average...
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