What You Should Know:
- Kaiser Permanente affiliates have agreed to a $556M settlement to resolve allegations of violating the False Claims Act by submitting invalid diagnosis codes to inflate Medicare Advantage (MA) payments.
- The settlement, involving multiple Kaiser Foundation and Permanente Medical Groups, addresses a decade-long "data mining" scheme designed to pad the bottom line by manipulating the risk-adjustment model.
The Core of the Conflict: Risk Adjustment vs. Care
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Revenue Cycle Management | News, Analysis, Insights - HIT Consultant
How Hospital M&A Momentum Shifted to Ambulatory and Behavioral Health in 2026
What You Should Know
- Kaufman Hall has released its year-end analysis for 2025, reporting a total of 46 hospital and health system transactions. While total transacted revenue hit a historical low of $18.5 billion due to a slow start in the first half of the year, momentum surged in Q4 with 17 transactions, including four "mega mergers" where the smaller party’s annual revenue exceeded $1 billion.
- Crucially, financial distress drove a record 43.5% of all transactions, a trend
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The Autonomous Revenue Cycle: Waystar Launches Agentic AI to Prevent Billions in Denials
What You Should Know
- Healthcare payment provider Waystar has announced the introduction of agentic intelligence to its cloud-native platform, marking a pivotal step toward the industry's first autonomous revenue cycle.
- Powered by the Waystar AltitudeAI™ engine and a dataset comprising 7.5 billion annual transactions, the new agentic network is designed to execute defined tasks and learn from outcomes with minimal intervention, significantly reducing administrative friction for
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HPS/PayMedix Secures $33M to Scale Guaranteed Healthcare Payments
What You Should Know
- HPS/PayMedix secures $33M in combined equity and debt financing to accelerate the growth of its healthcare financing and payments platform.
- Led by HLM Investment Partners, the funding will be used to expand the PayMedix solution, which unifies all healthcare stakeholders through guaranteed provider payments, interest-free patient financing, and a consolidated SuperEOB® experience.
The Affordability Mandate: Unifying the Payment Experience
As
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FinThrive Report Reveals 71% of RCM Leaders Prioritize Experience Over Revenue
What You Should Know
- FinThrive's 2026 Transformative Trends Report marks a historic turning point: for the first time, improving the patient experience has surpassed increasing revenue as the top strategic goal for healthcare financial leaders, with 71% identifying it as their primary focus.
- The shift indicates that leaders are moving away from short-term fixes toward AI-enabled platform consolidation and automation to drive long-term stability and workforce
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Zelis Acquires Rivet to Bring AI-Powered Analytics to 750+ Providers
What You Should Know
- Zelis, a global leader in healthcare financial modernization has acquired Rivet, a pioneer in revenue cycle analytics. Financial details of the acquisition were not disclosed.
- The deal integrates Rivet’s AI-enabled analytics and intuitive dashboards directly into the Zelis platform, providing 750+ payers and millions of providers with actionable data to reduce denials, minimize "rework," and navigate rising regulatory complexity.
The Intelligence Layer:
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Abridge and Availity Partner to Automate Prior Authorization at the Point of Conversation
What You Should Know
- Abridge, the leader in clinical conversational AI, and Availity, the nation’s largest health information network, have launched a first-of-its-kind collaboration to automate prior authorization in real-time.
- By embedding Availity’s FHIR-native Intelligent Utilization Management solution into Abridge’s Contextual Reasoning Engine, the partnership aims to provide clinicians with visibility into coverage requirements and enable payer determinations during the
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Penguin Ai Launches Snowflake Native App to Automate HCC Risk Adjustment
What You Should Know
- Penguin Ai has announced the launch of its Hierarchical Condition Category (HCC) Coding & Risk Adjustment solution as a Snowflake Native App.
- By bringing its risk-adjustment intelligence directly into a customer’s Snowflake environment, Penguin Ai enables Medicare Advantage (MA) plans and risk-bearing providers to automate diagnosis extraction and improve Risk-Adjustment Factor (RAF) accuracy without moving or exposing sensitive patient data.
The "Data
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The 40% Difference: Why AI Must Anchor Your RCM Modernization Strategy in 2026
The Crisis Facing Healthcare Financial Leaders
Healthcare financial leaders are navigating an environment of unprecedented complexity. Your organization is caught between escalating operational costs and a relentless denial rate fueled by increasingly sophisticated payer tactics. The truth is, if your Revenue Cycle Management (RCM) is reliant on manual, legacy systems, you are accepting a permanent, self-inflicted fiscal vulnerability.
Industry data confirms this exposure: upwards of 10%
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Denial Management: Closing Gaps and Reducing Revenue Leakage
Revenue leakage on the front end and mid-cycle is an ongoing challenge for hospitals and health systems. Rather than taking a reactive approach to the problem, proactively collaborating among teams prior to admission helps providers avoid playing the blame game when their claims are denied after the fact.
By focusing on reducing the number of denials before a claim is submitted, rather than trying to eliminate denials after the fact, revenue cycle managers can save time and energy. Today’s AI
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