Risk adjustment involves billing diagnosis information that is properly supported in the medical record. It estimates the expected annual cost of care and aligns payments to the complexity of a patient’s conditions. Because payments rise with diagnosis severity, an...
Recent actions by the Centers for Medicare & Medicaid Services (CMS), including targeted spending reviews and the Comprehensive Regulations to Uncover Suspicious Healthcare initiative, known as CRUSH, reflect a measurable shift in federal oversight expectations....
AI is transforming how healthcare payers protect their dollars. One of the best places to see this impact is in payment integrity. This is where health plans can use AI to prevent fraud, waste, abuse, and errors (FWAE) before claims are paid. It’s fast, effective, and...
