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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...

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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...

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Must-Have Compliance Capabilities to Manage Risk and Help Drive Growth

Must-Have Compliance Capabilities to Manage Risk and Help Drive Growth Thorough RCM processes address a myriad of compliance issues that can cost an organization money, business freedom, and even exit opportunities. Compliance requirements are continually changing, and any misstep could result in lost revenue, fines, and even extreme penalties such as debarment, corporate integrity agreements,...

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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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Best Practice to Maximize Patient Collections Now that the HRSA COVID-19 Uninsured Program has Ended

On March 15, 2022, the Health Resources and Services Administration (HRSA) announced that the Uninsured Program would stop accepting claims as it had exhausted its federal pandemic funding. In the COVID-19 Uninsured Program Shutdown FAQs, HRSA stated: Claims submitted after March 22 for COVID-19 testing and treatment, and after April 5 for vaccination will not be adjudicated for payment. ...

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Considerations When Selecting an LIS for Gynecologic Cytology and Molecular Testing

Laboratories leaders investigating LIS solutions for Gynecologic Cytology and Molecular testing need dynamic solutions that meet all productivity and efficiency goals and regulatory requirements. Other essential factors include cytotech reporting, automated quality control review and reporting, pathology oversight and reporting, Bethesda reporting guidelines, management reporting, lookback...

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Mitigating 2023 Proposed Medicare Reimbursement Cuts

Over the past few years, due to the public health emergency (PHE), Congress has stepped in to halt pending Medicare cuts. However, legislative intervention during the PHE only delayed the cuts until the following year. With the proposed 2023 Medicare Physician Fee Schedule released in July, which contained several reductions, and the return of the 2% sequestration, healthcare providers need to...

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Laboratory Test Claim Denials and Appeals Trends

I recently had the privilege of presenting an in-person workshop in conjunction with The Dark Report Executive War College on Laboratory and Pathology Management. The workshop was on the topic of “Latest Trends and Denials Involving Lab Test Claims.” In this session, I shared XIFIN insights into payor behavior changes and shifting claims processing protocols and highlighted the importance of a...

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