AppriseMD’s Post

In our pursuit of a more efficient and transparent healthcare system, prepay edits serve as a critical frontline defense. These edits are designed to catch and correct errors before claims are processed and payments are made, ensuring accuracy and minimizing the risk of fraud. Here’s why prepay edits are essential: ✅ Data Validation: Each claim undergoes thorough scrutiny to verify patient information and medical coding. Discrepancies prompt immediate edits, requiring further clarification to proceed. ✅ Policy Compliance: Claims are rigorously checked to ensure they align with evidence-based rules and health plan policies. Non-compliant services are promptly identified and referred for additional review, reinforcing adherence to policy specifications. ✅ Benefit Utilization Checks: Prepay edits ensure claims do not exceed predefined benefit caps, preventing over-utilization of services. ✅ Coding Accuracy: Accurate medical coding is critical. Prepay edits assess the precision of coded data to prevent billing errors and potential inconsistencies. ✅ Duplicate Claim Detection: Identifying and addressing duplicate claims is essential for controlling costs and preventing redundant payments. By addressing issues upfront, prepay edits streamline the claims process, reduce the need for costly corrections, and enhance operational efficiency. This proactive approach builds trust between payers and providers, ultimately leading to a more reliable healthcare system. By leveraging AI and predictive analytics, it's possible to transition post-pay capabilities into the prepay stage to further enhance claim accuracy, reduce administrative burdens, and foster stronger relationships within the healthcare ecosystem. Together, prepay and postpay edits form a comprehensive framework that can ensure payment integrity, mitigate financial risks, and enhances the reliability of healthcare payments. #HealthcareInnovation #ClaimsIntegrity #PrepayEdits #SimplifyingtheBusinessofCare https://lnkd.in/gNJzGJa8

🚨 Claims Denials on the Rise: A Growing Challenge 🚨 A recent survey highlights a significant increase in payer denials from 2022 to 2024, leaving healthcare offices and hospitals grappling with financial strain. Contributing factors like rising physician fees and policies such as the No Surprises Act are reshaping the landscape of healthcare finance. 🔍 Tackling these challenges requires a strategic approach, including robust denial management systems, accurate medical coding, and staying updated on regulatory changes. This is where leveraging AI in Medical Coding and Billing can make a real difference. Advanced tools powered by AI can enhance accuracy, streamline workflows, and reduce errors, offering a solution to mitigate the impact of rising denials. Explore more about this critical trend and discover how you can stay ahead in the evolving world of healthcare. ➡️ Read the full article here: https://hubs.la/Q02Zy9CW0 For those looking to upgrade their skills, the AI in Medical Coding and Billing course from AAPC https://www.aapc.com/ is an excellent starting point. Let’s discuss: How is your organization managing the rise in denials? #claimsdenials #healthcaretrends #payerissues #healthcarefinance

A great use of AI scribes is to help in the self auditing process. I have used #HippoScribe to create clinical documentation, but then I also use it to audit the clinical documentation against published payer policy. ... I have templates and self audits created and based on specific payer policy: Unitedhealthcare, Aetna, Medicare, etc. ... We all make mistakes. The problem isn't making a mistake, the problem is not having an internal audit process that finds the mistake, fixes the mistake, and updates the policy/procedure to never make the mistake again!

Medicare Advantage Ramp-Up AI Technology to Deny Claims: A Senate Investigation Reveals Concerning Patterns A recent Senate investigation reveals that major Medicare Advantage (MA) insurers are leveraging advanced technology to expedite claim denials, with substantial implications for the millions of Americans relying on Medicare Advantage for post-acute care coverage. UnitedHealth, Hu https://buff.ly/40jactl

AI and prepayment claims editing are vital for improving payment accuracy in #healthcare, reducing costs, and enhancing payer-provider relationships. Early intervention minimizes post-payment interventions, while collaboration between solution providers and payers ensures targeted offerings. Automation and advanced analytics empower professionals to focus on #PatientCare. #AIInHealthcare

What started as a way of administering care during the pandemic, doctors are now overwhelmed with online patient queries, and some doctors have turned to AI-generated responses to save time. Although fewer than a third of messages are sent unedited to patients, this still raises interesting questions, especially if the patient believes they are really speaking with their physician. For one clinician, whether to disclose use of the AI tool comes down to a simple question: What do patients expect? “Even if it was flawless, do you want to automate one of the few ways that we’re still interacting with each other?” #innovation #healthcare #healthcareinnovation #genai #healthai

Not one, not two, but three separate reports were published this week on managed care abuse. Insurers used unsupported diagnoses, AI algorithms, and incorrect coding to serve their bottom line, patient care paid the price. ▪️ The Wall Street Journal highlights an Office of Inspector General report showing $4.2 billion in extra payments to Medicare Advantage companies in 2023 through unsupported diagnoses during home visits, where patients did not receive care for said diagnoses. ▪️ ProPublica investigates EviCore’s system for denials, nicknamed "the dial," is a proprietary AI algorithm that’s the first stop in evaluating a prior authorization request. EviCore can adjust the algorithm to increase the number of requests sent for review, increasing the likelihood of a denial.   ▪️ A new analysis by Kodiak Solutions shows that from July 2023 to June 2024, Medicare Advantage (MA) plans classified hospital stays as observation visits three to four times more frequently than traditional Medicare.

According to NYTimes, Epic has made a wrapper around OpenAI’s API and draft messages for patients on behalf of physicians, resulting a risk of severe harm about 7 percent of the time. That’s why companies like us spend months building our custom models, validating and verifying answers, and making sure we bring the possible harm to almost zero, answers are factually correct, and easily understandable by the patient. What is interesting is that some healthcare executive asks “Epic is already doing it or it is on their roadmap, why you are doing it?”. This is the answer: Even Epic can not be everything to everyone! Open call: as reported in our paper, we claim answers to medical questions provided by our AI is 98%-98% correct. If you are a physician, you are welcome to try it out! #trustworthyai #healthai #healthcareai https://lnkd.in/gfvkr9Sd

Is Your REACH ACO Still Scrambling for 2024 HEDR Data? Here’s the deal: CMS expects REACH ACOs to collect SDoH data from patients, but: - Most practices don’t routinely do it. - EMR exports are a nightmare. - Only three CMS-approved screeners are accepted—no hybrids allowed. The clock’s ticking, and that 0.2% revenue adjustment (~$25 per patient) isn’t going to collect itself. For an ACO with 20,000 patients, it's $500K to earn or lose. Solution? Let AI assistants do the heavy lifting. They can call patients, collect responses, and log them—fast. You’ve got time to act before the quality withhold hits. How’s your PY24 strategy shaping up? Let’s talk about keeping that revenue in your pocket.

"We want to disrupt the healthcare system with our AI / Precision medicine platform", PLEASE DON'T. At this point, I have heard so many start-up pitches that want to revolutionize the healthcare system (with a new EMR system, new diagnostic software, new approach, etc.) It's a great vision and should be achieved in due course, but when you start building, start with a way to integrate with current workflows and embed seamlessly somewhere in the process. Healthcare practitioners are already burned out. Adding one more tool with one more sign-in/account/platform to learn and manage, while beneficial to them or the patient is only gonna increase the burden. Leverage the 'systems design approach'. Think about how you can integrate into the current workflow or bundle with existing pieces of software on their screen and minimize the number of steps (clicks) needed. Enter and expand. Plus it is the only industry where consumers (patients), customers (healthcare practices), and payers (insurance or employer) are different. It is so difficult to create benefits for all stakeholders, who have vested interests in keeping things the way they are. I would love to hear any supporting or contradicting views. Please share your comments.