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Another payor-provider breakup

What are hospital systems supposed to do if insurers refuse to play fair? As of February 1, Blue Cross Blue Shield of Arizona (BCBSAZ) is out of network with San Francisco-based Dignity… Read More

Premium dollars or lives? For BCBSNC, we’re not sure there’s a difference.

Blue Cross Blue Shield of North Carolina has been booted . . . from the state health plan, that is. For decades, hundreds of thousands of North Carolinians have been getting their… Read More

No surprises here: Insurers failing to uphold their end of the No Surprises Act

It seems simple: Established in 2022, the No Surprises Act seeks to limit the amount of out-of-pocket expenses that patients might get stuck with when their insurance company is out of network… Read More

Hey North Carolina, be wary of BCBSNC’s growth plan.

In our healthcare ecosystem filled with disruptors, some health insurance companies are trying to take a (very big) bite. At least, that’s what Blue Cross and Blue Shield of North Carolina (BCBSNC)… Read More

Some insurance companies employ doctors with medical malpractice suits to review claims.

Where do doctors with malpractice claims go? In some cases, to insurance companies. To be sure, not all doctors working for insurance companies have faced malpractice suits, nor do all who have… Read More

Yet another health insurance company is using AI to deny medical claims.

It’s 2024, and AI is in the air — it’s everywhere. Especially in healthcare. Whether it’s imaging software that can help doctors quickly identify and diagnose diseases; predictive insights that help optimize… Read More

An insurance merger is back from the dead—but who benefits?

It’s a new year, and one with big opportunities for the powers that be at Elevance Health. As of mid-December, the health insurance giant’s $2.5 billion acquisition of Blue Cross and Blue… Read More

We don’t care, say insurers: Payors bypass state laws and deny care.

North Carolina. Oklahoma. Michigan. Maine. Arizona. California. These are just some of the states where health insurance companies are denying patients their due care — and, as a result, lawmakers are speaking… Read More

It’s the battle of the PBMs.

It’s the battle of the pharmacy benefit managers (PBMs). If you need a refresher, PBMs are third-party companies that health insurance companies use to handle prescription drug benefits for their health plans.… Read More

Another algorithm to say ‘no’ to your care

Nice try, UnitedHealthcare . . . The nation’s largest health insurer has recently found itself in hot water over an algorithm it uses to deny rehabilitation care for Medicare Advantage beneficiaries. According… Read More

Prior authorization reform? We’ll believe it when we see it.

You know when someone says they’re sorry only because they got caught? That’s what it feels like with health insurers and prior authorization reform. Even though some of the largest health insurance… Read More

The data keeps rolling in — claim denials continue to impact patient care

Health insurance companies continue to cook up creative strategies to shortchange health systems through underpayments, non-payments, and — it’s the big one! — claim denials. These strategies reduce what gets reimbursed to… Read More

Insurance companies continue to squeeze dollars out of Medicare Advantage

Let’s say you run a big, unwieldy, expensive government program. You want to trim costs, but your program provides services in all 50 states for more than 65 million Americans, and you… Read More

A conflict of many interests: Cloverfields Capital Group and its ties to UnitedHealth Group

When it comes to avoiding insider trading, guess we’ll just have to take UnitedHealth Group’s word for it. The sticky situation is this: Stephen Hemsley, the former CEO of UnitedHealth Group and… Read More

Deflecting blame is an insurer’s specialty

It’s that time of year again . . . insurers across the country are starting to release their 2024 rates. It’s also that time of year again when insurers deflect their rate… Read More

Expect to be denied: Claim denials are on the rise

If there’s one thing you can count on in the American healthcare system, it’s claim denials. At least, that’s what the research tells us. According to a recent Kaiser Family Foundation (KFF)… Read More

Doctors are slapped with fees when opting for electronic funds

Insurers will do just about anything to make a buck. Including taking money owed to physician practices and hospitals. According to an article from ProPublica, insurers take cuts from physician reimbursements if… Read More

Doctors and patients are getting loud online. Here’s why.

North Carolina resident Sally Nix has had enough with prior authorizations. Afflicted with a combination of autoimmune diseases since 2011, brain and spinal surgeries failed to relieve Nix’s chronic pain and fatigue.… Read More

Another survey reveals the dark underbelly of commercial health insurers

Back in July, the American Hospital Association (AHA) released findings from three surveys conducted by Morning Consult on the practices of commercial health insurers. The findings weren’t great. Patients, nurses, and physicians… Read More

Prior authorizations are (still) a bad idea.

We’ve said it before, and we’ll say it again: Prior authorizations are a bureaucratic bad idea. At least, they are for physicians and patients. But while prior authorizations can be a minor… Read More

UnitedHealthcare rolled back its prior authorization policy. But ‘advance notification’ might be even worse.

Earlier this spring, UnitedHealthcare (United) announced plans to effectively use prior authorizations as blockades to colonoscopies. Any patient seeking a surveillance or diagnostic colonoscopy to detect cancer would first need approval from… Read More

Hospitals are struggling as costs rise. Insurers aren’t helping.

Hospitals are struggling. And according to a new report from the American Hospital Association (AHA), health insurers aren’t doing anything to make it easier. In fact, they’re making it worse. After a… Read More

Medical billing: another way payors exert their power over hospitals

Ever wonder how hospitals and doctors’ offices get paid for the services they provide? Many of us know that insurers pay for some of the care patients receive, but how does a… Read More

Big surprise: NC insurers push back on covering patient care

Like other states, many in North Carolina struggle to access quality healthcare. Several bills are in review by the state’s House Health Committee, many of which seek to improve access for patients… Read More

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