Tag: cost management

BRENTWOOD, Tenn., and GAITHERSBURG, Md., October 3, 2024 – Today ClarisHealth, provider of the leading integrated payment integrity technology platform for health plans, announced a strategic partnership with Expion Health. ClarisHealth is pre-integrating Expion Health into the Pareo® platform to offer enhanced out of network (OON) claims management capabilities designed to detect and avoid more claims overpayments without … ClarisHealth Partners with Expion Health to Offer Enhanced Out of Network Claims Management Services on the Pareo® Platform

It’s not uncommon for facilities or PPO networks to assert that a claim is DRG-based to deter payors from pursuing further review. On the surface, this might seem like a dead end for an Itemized Bill Review, but that’s not always the case. When informed that a claim was repriced at a DRG, it’s crucial … The Power of Probing: Why You Should Question DRG-Based Claims

The concept of ethical administration has rapidly become a hot topic – so much so that it is the theme of this year’s Health Care Administrators Association (HCAA) TPA Summit. This post, inspired by insights from Nicholas Stone, SVP, Medical Cost Containment Sales at Expion Health, examines what constitutes “Ethical Administration,” aiming to highlight the … Choosing the Right Partners: Administrators’ Quest for Vendors Committed to Ethical Administration in Non-Network Claims

The Federal government recently proposed changes to the NSA IDR process in hopes of holding all involved organizations more accountable and forcing initiating and non-initiating parties to be more diligent in documentation and timely admin fee payments. While the end goal may be to increase speed, efficiency, tracking and transparency, the immediate result is health … Get Ready: CMS Proposes Numerous Changes to IDR Process

NSA currently excludes Urgent Care and Ground Ambulance services despite pressure to do so. However, some states have begun to provide protection. This means self-funded employers must determine which coverage to use. What may seem like the right path may not always make the most economic sense. To ensure the best savings, self-funded plans should … NSA Minute: Ground Ambulance & Urgent Care Services

Payers grapple with the complexities of the No Surprises Act (NSA), but self-insured plans face an added challenge in states that allow plans opt-in to state laws instead of the federal law. Selecting between state or federal laws demands careful analysis of factors such as: breadth of protections, data inputs allowed for payment determinations, claims … Navigating the No Surprises Act: The State vs. Federal Balance Billing Dilemma

As our hearts and prayers go out to Damar Hamlin and his family for a speedy recovery after his on-field medical emergency, we are reminded of the complexities of emergency care, especially if ongoing care is needed. Even after the immediate crisis has passed, post-stabilization care may still be needed. The No Surprises Act has been instrumental … NSA Minute: Separating NSA and Post-Stabilization Codes

The use of biosimilar products in lieu of originator biologic products has been a hot topic of discussion since the first FDA approval of Zarxio (a biosimilar for Neupogen) in 2015. Since then over 30 new biosimilars have been FDA approved but the biosimilar market hasn’t taken off as expected. The slower than expected uptake … The Impact of Humira Biosimilars: 5 Factors That Will Reduce Payer Costs