California-based Zing Health latest to join SDoH market of payers. Since 2018, there has been common language introduced by insurers that includes the verbiage “so-and-so is uniquely positioned to address the SDoH (social determinants of health),” all followed by, “with new programming” promising to: Enhance health outcomes; Be customized to…
Protecting patient rights is one of the cornerstones of Medicare policy. As a doctor, I can assure you that I would rather patients concentrate on their health and not worry about whether their medical providers or their insurers are making decisions for them based on considerations that are not in…
Medicare Advantage plans appear to be following their own rules. Many of the national Medicare Advantage (MA) plans are misusing commercial guidelines and making up their own rules, as they see fit, in order to avoid paying hospitals equitably for the care provided to their members. That was the assessment…
This case of goes beyond DSH payments. Earlier this month the U.S. Supreme Court decided an appeal brought by Allina and many other hospitals challenging the methodology the government used when calculating disproportionate share payments. But even if this sounds irrelevant, don’t stop reading, because this decision will have an…
Medicare Advantage Plan contracts are “take-it-or-leave-it” agreements Many questions are swirling about regarding Medicare Advantage Plan (MAP) denials asking what to do about the increasing number and given reasons.  I’ve heard or read some amazing stories where payers have gone to astounding lengths to deny claims.  Answers are also swirling…
A Manhattan Institute senior fellow makes his case for Medicare Advantage. A prominent conservative healthcare policy expert had a simple message in a recent opinion column: before diving into a debate over the prospects of “Medicare for All,” maybe Medicare needs a bit of tinkering first. Manhattan Institute Senior Fellow…
There are steps providers should take for holding managed care plans accountable. Considerable effort is regularly devoted by healthcare providers to overcome coverage denials through the application of the governing rules, such as they can be leveraged. Following the rules is tough in a world where money talks, bringing us…
The debate over the controversial two-midnight rule rages on. Ok, I surrender. “This is not the hill I intend to die on” is an accurate metaphor. There has been here at RACmonitor a flurry of concern, debate, troubled investigation, and notice of dodging by health plans, and, as we’ve come…
Controversy continues to swirl around this subject. A recent article of mine focused on the argument that Medicare Advantage (MA) plans have to follow the two-midnight rule. It certainly generated buzz; I received a number of emails with comments and questions. First, I want to note that I love getting…
The total denial per claim can run in the tens of thousands of dollars. Chuck Buck has asked me to share with you our experiences here at the University of Wisconsin regarding so-called “forensic” audits done on our outlier claims, which we are receiving from a review firm called Equian.…
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