Risk adjustment requires constant attention to ensure accurate coding, timely regulatory compliance, and streamlined communications across the payer-provider continuum. Increasingly rigorous oversight from the Centers for Medicare & Medicaid Services (CMS) and Office of the Inspector General (OIG) are calling for better diligence, planning and administrative oversight for effective risk adjustment.
The January 2023 rule from CMS, which struck the fee-for-service adjuster from risk
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Revenue Cycle Management | News, Analysis, Insights - HIT Consultant
Edifecs and HealthEdge Partner to Streamline Healthcare Data Exchange
What You Should Know:
- Edifecs and HealthEdge, two leading healthcare technology companies, have announced a strategic partnership to natively integrate Edifecs’ EDI Gateway offerings with HealthEdge’s HealthRules Payer claims adjudication system.
- This partnership will enable organizations to confidently navigate complex regulatory landscapes while also laying the foundation for future advancements in healthcare administration.
Enhancing Healthcare Data
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The Critical Importance of Payer-Provider Collaboration Goes Beyond Prior Authorization
The critical need to improve prior authorization processes might have reached its tipping point on Jan. 17. That’s when the Biden administration announced its new mandate — the CMS Interoperability and Prior Authorization Final Rule — designed to effectively speed up the process for Medicare Advantage patients, providers and health plans.
Speed is only one of many inefficiencies surrounding prior authorization. And prior authorization cases are only one slice of the patient
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CorroHealth Acquires Xtend Healthcare’s RCM Business from Navient
What You Should Know:
- CorroHealth, a healthcare technology and revenue cycle management (RCM) company, has successfully completed its acquisition of Xtend healthcare's RCM business from Navient.
- The acquisition significantly scales CorroHealth's existing RCM capabilities and introduces new patient engagement features. Notably, it adds multichannel patient communication functionalities, a crucial element previously missing from CorroHealth's suite of services.
- As part
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AI Agents in Healthcare: Retaining Talent, Improving Patient Care
The aging population is creating an unprecedented demand for healthcare services while the available healthcare workforce is declining. Meanwhile, the healthcare system continues to rely heavily on manual processes which have to date been powered by people. After a patient visit, a healthcare provider typically requires a full administration team to manage data across various systems, just to receive reimbursement
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Candid Health Secures $29M for Revenue Cycle Automation Platform
What You Should Know:
- Candid Health, the innovative revenue cycle automation platform designed for healthcare providers raises $29M in a Series B funding round led by 8VC, with participation from existing investors First Round Capital, BoxGroup, and Y Combinator.
- This latest investment brings the company's total funding to $47M.
Simplifying Medical Billing, Empowering Providers
Candid Health is committed to simplifying the complex and often frustrating process of medical
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CPT 2025 Code Set Released, Featuring AI Integration, Digital Medicine
What You Should Know:
- The American Medical Association (AMA) has released the CPT® 2025 code set, a comprehensive update that reflects the latest advancements in medical procedures and services.
- This year's release features 420 total changes, including 270 new codes, 112 deletions, and 38 revisions.
Key Updates in CPT 2025
CPT codes are essential for data sharing, billing, and reimbursement in the healthcare industry. The CPT 2025 code set was developed through a
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Navigating the Murky Waters of Healthcare Billing
The traditional fee-for-service healthcare model, which reimburses providers based solely on the quantity of services delivered, is undergoing a much-needed transformation. The choice now is of value-based care initiatives, that are more focused on improved patient outcomes and preventive care, rather than simply paying for services rendered.
At the core of this change is a fundamental realignment of the mission, processes, metrics, and cultural values for healthcare providers and clients,
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AI’s Advantages to Overcoming Revenue Cycle Management Challenges for Providers
Healthcare providers face staffing shortages, increasing regulatory requirements, and pressure to reduce costs while delivering effective care. Compounding provider problems are payor policy, behavior changes and ongoing fee schedule cuts that compress revenue, as well as mounting denials and additional documentation requests from payors.
Coding, claim processing, and the collective revenue cycle management (RCM) tasks required to ensure appropriate reimbursement for billable service are all
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5 Ways AI Streamlines Prior Authorization Process for Providers & Patients
The prior authorization process, integral for confirming the necessity and insurance coverage of medical treatments, has historically been an obstacle in healthcare. In its current state, it has the potential to cause considerable delays and financial burdens for patients and healthcare providers - and the inefficiencies of this process are evident, as approximately 90% of providers report care delays due to this process (AMA), with a significant percentage indicating that some delays even lead
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