Category: Payer

Medicare Star Ratings Improvement: 2027 Strategies for Payers

2027 Star Ratings: Turning Priorities into Progress The 2027 Star Ratings are out, and health plans are looking closely at what contributed to their results. Some will be working to regain lost ground, while others will be focused on maintaining performance. Regardless, both will need staff who can work through medical records carefully, apply the […]

Utilization Management vs. Case Management: What’s the Difference?

Utilization Management (UM) and Case Management (CM) are essential healthcare functions that ensure patients receive appropriate, coordinated, and cost-effective care. While the two disciplines often work closely together, they serve different purposes. Utilization Management focuses on whether services are medically necessary, appropriate, and covered under a health plan. Case Management focuses on coordinating the care, […]

How to Develop a Successful Utilization Management Program

Nurse at computer

Utilization management (UM) helps lower costs and improve outcomes by ensuring members receive the most appropriate care in a timely, cost-effective manner. Initially, UM was primarily focused on reducing excessive use that leads to waste without any measurable gains in quality or outcomes. The focus has now expanded to encompass improving quality and regulatory compliance […]

Improving Patient Care with Coding

The healthcare industry has been no stranger to shortages of qualified workers over the few years, and the coding workforce is no exception to this trend. There is a need for more medical coders across the U.S., making it increasingly more challenging to find skilled and credentialed coders who can execute the specific type of […]

Health Insurance Claims Analysis

A current trend in the Healthcare industry is the increasing volume of inpatient claims denied by payers based on lack of medical necessity. While Medicare offers detailed payer categories compared to other providers, they also reject the highest number of shares. However, from 2021 to 2022, the inpatient claim denial saw a rise of 18.5% […]

Coding Around the Clock (and Around the World!)

By Melanie Kiss-Endicott, MBA/HCM, RHIA, CDIP, CHDA, CPHI, CCS, CCS-P, FAHIMA The demand for experienced, certified medical coders is a constant challenge for healthcare organizations. One solution for this demand is outsourcing medical coding to companies with offshore coders to supplement your current team. Offshoring has several benefits, including cost savings, a highly qualified labor […]