On April 5, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that requires Medicare Advantage (MA) plans to follow traditional Medicare laws for coverage decisions, limits the use of prior authorization, mandates continuity of care for Medicare beneficiaries and establishes a Utilization Management (UM) Committee with a heightened standard for adverse medical necessity decisions.
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One common reason for health systems to exit a payor’s network is the inability to reach mutually agreed-upon reimbursement rates and terms during contract negotiations. Years of challenges with timeliness, accuracy and costs of pursuing full reimbursement from an insurance company often lead to this last-ditch effort.
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Healthcare revenue cycle management (RCM) covers the business side of healthcare and includes all tasks associated with the management and collection of revenue generated by healthcare organizations from patient care episodes, from initial patient intake through complete payment collection.
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