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Medical billing, coding, denials, credentialing, PCMH and practice operations, written to be useful on Monday morning.
CMS Finalizes the Prior Authorization Rule: What Changes in 2026 and 2027
On January 17, 2024, CMS released the Interoperability and Prior Authorization final rule (CMS-0057-F). It sets decision deadlines, requires specific denial reasons and mandates a prior authorization API. Here is who it covers, when each piece lands and what to do before then.
Medicare Advantage Now Covers a Majority: Preparing Your Practice for January
Medicare open enrollment runs October 15 to December 7, 2023. KFF reports that 30.8 million people, 51% of eligible beneficiaries, are in Medicare Advantage this year. Here is what plan switching does to a practice in January, what the CMS-4201-F prior authorization rules change on January 1, and how to prepare now.
UnitedHealthcare and Cigna Cut Prior Authorization: What Changes in Practice
UnitedHealthcare published the codes it will stop requiring authorization for on September 1 and November 1, 2023, about a fifth of its volume. Cigna followed on August 24 with more than 600 codes. Here is what is actually changing, what is not, and how to adjust the authorization workflow without creating new denials.
Writing Denial Appeal Letters That Actually Get Read and Overturned
Most appeal letters fail before a reviewer reaches the second paragraph. Here is the structure we use, the three denial types where a letter is worth writing, the documents to attach, the deadlines to log, and the mistakes that get an otherwise good appeal sent back unread.
Billing Staffing Shortages in 2023: Running the Revenue Cycle With Fewer People
MGMA polling this spring found coders and billers are the hardest revenue cycle roles to fill, and turnover in business operations staff topped 33% last year. Here is how the practices coping best are cutting rework, automating the repetitive checks, cross-training, and deciding what to send out.
UnitedHealthcare's 20% Prior Authorization Cut: What Changes for Practices
UnitedHealthcare says it will drop prior authorization for about a fifth of its procedure volume starting in Q3 2023, days after an AMA survey found 94% of physicians see care delayed by authorizations. Here is what was announced, what CMS finalized the same week, and how to run the desk regardless.
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