Health systems face rising case complexity, thin specialty coverage and operating margins too tight to absorb preventable revenue loss. Denials and misclassified patient status quietly drain dollars that smaller systems can least afford to lose. A nonprofit health system serving…
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Physicians in value-based contracts are doing two jobs at once: delivering care and proving it. Risk adjustment, quality reporting and payer-specific documentation all land on the same clinicians already spending 5.3 hours in the EHR for every eight hours of…
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For most health plans, social risk lives inside care management, disconnected from strategy and the balance sheet. The result is avoidable utilization no one has quantified and spending no one has traced to a cause. As medical costs climb and…
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Austin, Texas-based St. David’s HealthCare, a partnership between Nashville, Tenn.-based HCA Healthcare and two nonprofits, is set to go out of network with Cigna Oct. 1. St. David’s hospitals, ASCs and affiliated hospital-based physicians in Texas will no longer be…
UnitedHealthcare’s Medicare Advantage business in Texas received an estimated $24.4 million in overpayments during 2020 and 2021 tied to diagnoses not supported by medical records, the HHS Office of Inspector General said in an audit report published Sept. 28. The…
Elevance Health plans to require hospitals to identify the physical location where care was provided on billing forms and adjust payments for off-campus services accordingly. The insurer said Sept. 29 the new policies will apply across its commercial, Medicare Advantage…
Texas Attorney General Ken Paxton launched an investigation into Blue Cross and Blue Shield of Texas and its parent company, Health Care Service Corp., over potential denials and delays of medically necessary care, as well as prior authorization concerns. Mr.…
Getting a payer file is easy. Trusting it is not. In a late-2025 survey of 56 hospital and health system C-suite leaders, 87% said claims data matters to value-based care. Only 35% were confident it was accurate. Just 11% called…
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When a health system sells its ambulatory laboratory operations, it collects a one-time payment and gives up the recurring revenue that testing would have earned for years. Many leaders underestimate how profitable ambulatory testing is, then watch the lost margin…
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Your health system already earned the revenue, and now it’s sitting in a fax queue, in a denial nobody had time to appeal, and in an authorization that’s been pending for three weeks. See how health systems are clearing those…
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