Blue Shield of California is being sued for allegedly issuing a wrongful blanket denial of all requests for coverage with the Coflex titanium implant to treat lumbar spinal stenosis....
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Nearly 36% of payments tied to FFS Alternatives
Offering alternative value-based payment options to payers differentiated you and delivered competitive advantages. Now, if you don't, you'll be left out. Are you ready to risk that?...
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High-Value Health Care: The Intersection of Quality, Affordability and Outcomes for Employers
Employers are uniquely positioned to positively influence the quality and cost of health care through direct-with-employer contracting. But they aren't sure whom to call and how to proceed. Neither are the providers......
Continue readingConsidering a Cash Pay Program? Check Your HMO/PPO Contracts for Conflicts!
A checklist for providers considering cash pay discounts for payment in full on the day of service might conflict with the payor contracts....
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Price Transparency: Ready Set Go!
New and significant hospital price transparency rules are proposed for hospitals in the USA. Will you be ready in less than 4 months?...
Continue readingLooking Back Ten Years: Managed Care, Medical Tourism, and more
Looking Back at the Past Ten Years: Managed Care, Medical Tourism, Concierge Medicine and Bundled-priced Surgery Case Rates...
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Where Can I find Managed Care Contract Negotiation Training?
Maria Todd, author of "The Managed Care Contracting Handbook" is the USA expert who offers Master Classes for working healthcare industry professionals...
Continue readingNeed Help to Appeal Denied/Rejected Claims?
Out of Network International insurers / health schemes Denied Workers’ Compensation Third-party liability (slip and fall, etc.) with Attorney Involvement Uninsured Motor Vehicle Accident Claims Lack of Medical Necessity Allegations that you lack proper authorization Coverage Exclusion or Exhaustion Pre-existing conditions on Travel Accident Insurance Denied vs Rejected A denied claim is one that an insurance...
Continue readingSample Contract Language: Utilization Management
Utilization management is a system for reviewing the appropriate and efficient allocation of health care services under a health benefits plan according to specified guidelines, in order to recommend or determine whether, or to what extent, a health care service given or proposed to be given to a covered person should or will be...
Continue readingWhy America’s Rural Hospitals Suffer under Shared Risk and Full-Risk Payer Contracts
In managed care agreements, payers regard rural and urban hospitals as “hospitals”, all uniform in character. But in reality, huge variations in the demography, economics, culture, and environmental characteristics of different rural places make them very different from their urban counterparts and distinctly different from their other rural competitors. Large rural and suburban bedroom...
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