What You Should Know:
- Prior authorization is mandated by payers to ensure that certain clinical procedures and medications being ordered are necessary. To alleviate the heavy administrative burden this requirement causes, healthcare organizations have adopted automated prior authorization solutions.
- For this report, KLAS interviewed 30 respondents from 26 unique organizations to understand their experiences using these solutions and what outcomes they have seen.
Understanding
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Prior Authorization
Why It’s Time for Intelligent Prior Authorization
The Centers for Medicare & Medicaid Services (CMS) recently proposed a new rule to advance interoperability and improve the prior authorization (PA) process for Medicare and Medicaid patients. Specifically, the rule stipulates that health plans adopt electronic prior authorization processes, adhere to shorter turnaround times, clearly communicate denial reasons, publish key metrics annually, and implement the Fast Healthcare Interoperability Resources (FHIR) Application Programming Interface
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Electronic Transactions Can Benefit Partnership Among Physicians, Insurers and TPAs
The patient is at the center of the healthcare experience, and rightfully so. However, a strong case can be made to place the physician at the center. After all, it’s the physician who diagnoses and treats the patient.
Insurance companies and third-party administrators (TPAs) also have critical roles to play in the care experience, bringing together networks of physicians, specialists, surgery centers, hospitals, ambulatory care centers, and more to create a comprehensive care experience for
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Edifecs and VirtualHealth Partner to Automate Prior Authorization
What You Should Know:
- Today, Edifecs and VirtualHealth, a medical management company, announced a new partnership automated prior authorization to VirtualHealth’s HELIOS® platform for healthcare payer and provider clients.
- The Edifecs solution will automate and optimize the prior authorization process across HELIOS to significantly reduce the administrative burden, alleviate friction between payers and providers, and ultimately expedite patient care.
Growing Need for Automated Prior
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9 Executive Revenue Cycle Predictions/Trends to Watch in 2023
Nate Maslak, the co-founder/CEO of Ribbon Health
Price Transparency: In 2022, we saw CMS’s Transparency in Coverage rule go into effect, requiring non-hospital entities like health plans and providers to publish publicly available rates for care. In 2023, we’ll see this price transparency data become more mainstream as it finally makes its way into the hands of patients, empowering them to find the best care for them, reevaluate their care choices, and shop around for the best possible care
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How to Empower Patients With Price Transparency
The evolution of e-commerce – led by Amazon – has created an intensely savvy consumer population. Amazon’s platform allows users to easily compare products from different vendors to get the best price. People travel to retail stores to try on clothes and shoes, only to purchase them online for less. Even the longest running game show in television history awards points for knowing how much consumer products cost.
Healthcare, on the other hand, does not engender the same kind of
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Prior Authorization Reforms Don’t Address the Real Problem. Here’s How AI Can Help.
After waiting weeks for an open appointment, John finally gets in to see the orthopedic surgeon to evaluate his acute knee pain. He’s already been off work for over two months and has barely been able to leave the house, popping anti-inflammatory and pain medicine to manage the pain every day.
Suspecting a torn meniscus, the doctor orders an MRI to verify the diagnosis and plan his treatment approach. The nurse begins the process by calling John’s insurance carrier to verify coverage,
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AdvancedMD to Roll Out 35+ Updates in Major Product Release
What You Should Know:
- AdvancedMD announced its 2022 Fall product release that includes 35 new features added to its suite of all-in-one medical office and remote care cloud software. This marks one of the largest product release updates in AdvancedMD history, reflecting the robust nature of the leading cloud-based platform used by more than 40,000 practitioners across 13,000 practices, and 850 medical billing companies.
- AdvancedMD’s fall release ensures more unified and smoother
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HLTH22 Day 3 News Summary
DispatchHealth Raises $330M for Hospital-at-Home Care
DispatchHealth, a provider of in-home medical care raises $330M led by Optum Ventures with support from current investors such as Humana (NYSE: HUM), Oak HC/FT, Echo Health Ventures and Questa Capital. New investors included Adams Street Partners, the Olayan Group, Silicon Valley Bank, Pegasus Tech Ventures and Blue Shield of California. Patients and their care partners can request DispatchHealth medical care via phone, mobile app, or
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Edifecs Partners with Empowered-Home to Deliver Automated Prior Authorizations
What You Should Know:
- Edifecs and Empowered-Home announced a partnership to provide automated prior authorizations to medical associations, Accountable Care Organizations (ACOs), Independent Physician Associations (IPAs), medical groups, and home health care agencies.
- The Edifecs prior authorization solution combined with the clinical decision support system of patient management software company, Privis Health, forms the backbone of Empowered-Home’s ecosystem. Empowered-Home is
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