# Reimbursement Issues * **Definition:** Reimbursement Issues refer to challenges and complications that arise in the process of obtaining payment from insurance providers or government programs for healthcare services rendered, including disputes over coverage, billing errors, coding discrepancies, and delays in payment. * **Taxonomy:** Healthcare Topics / Reimbursement Issues ## News * Selected news on the topic of **Reimbursement Issues**, for healthcare technology leaders * 2.5K news items are in the system for this topic * Posts have been filtered for tech and healthcare-related keywords | Date | Title | Source | | --- | --- | --- | | 5/20/2025 | [**Ambulatory Surgical & Emergency Center Services Market 2025: AI, Electrification, and ...**](https://www.linkedin.com/pulse/ambulatory-surgical-emergency-center-fotve/) | [[Linkedin]] | | 5/5/2025 | [**Reimbursement Trends May Reshape Rural Emergency Healthcare Services**](https://www.beckershospitalreview.com/strategy/reimbursement-trends-may-reshape-rural-emergency-healthcare-services/) | [[Beckers Hospital Review]] | | 4/23/2025 | [**Marketing company operators sentenced to prison for roles in $127M fraud scheme**](https://www.beckershospitalreview.com/legal-regulatory-issues/marketing-company-operators-sentenced-to-prison-for-roles-in-127m-fraud-scheme/) | [[Beckers Hospital Review]] | | 4/19/2025 | [**HIMSS Changemaker recommends investing time to mentor - Healthcare Finance News**](https://www.healthcarefinancenews.com/video/changemaker-recommends-investing-time-mentor) | [[Healthcare Finance]] | | 4/16/2025 | [**How Has Healthcare's Approach to Telehealth Changed in the Past 5 Years?**](https://healthtechmagazine.net/article/2025/04/how-has-healthcares-approach-telehealth-changed-past-5-years) | [[HealthTech Magazine]] | | 4/8/2025 | [**For hospital IT purchasers, resource strain and optimal ROI are top concerns**](https://www.healthcareitnews.com/news/hospital-it-purchasers-resource-strain-and-optimal-roi-are-top-concerns) | [[Healthcare IT News]] | | 4/1/2025 | [**ATA Action acquires Digital Therapeutics Alliance to launch new coalition**](https://www.healthcareitnews.com/news/ata-action-acquires-digital-therapeutics-alliance-launch-new-coalition) | [[Healthcare IT News]] | | 3/21/2025 | [**Healthcare Providers & Services Stocks Q4 Teardown: Cardinal Health (NYSE:CAH) Vs The Rest**](https://finance.yahoo.com/news/healthcare-providers-services-stocks-q4-090136952.html) | [[Yahoo Finance]] | | 3/13/2025 | [**Big challenges health system IT execs in the next 12 months - Becker's Hospital Review**](https://www.beckershospitalreview.com/healthcare-information-technology/big-challenges-health-system-it-execs-in-the-next-12-months.html) | [[Beckers Hospital Review]] | | 3/13/2025 | [**Big challenges for health system IT execs in the next 12 months**](https://www.beckershospitalreview.com/healthcare-information-technology/big-challenges-health-system-it-execs-in-the-next-12-months/) | [[Beckers Hospital Review]] | | 3/11/2025 | [**HIMSS25: Driving Payer Innovation with AI, Digital Health and Collaboration**](https://www.healthitanswers.net/himss25-driving-payer-innovation-with-ai-digital-health-and-collaboration/) | [[Health IT Answers]] | | 2/13/2025 | [**Remote Patient Monitoring Market to Hit USD 56.94 Billion by 2030 with 12.7AGR - MarketsandMarkets™**](https://www.prnewswire.com/news-releases/remote-patient-monitoring-market-to-hit-usd-56-94-billion-by-2030-with-12-7-cagr--marketsandmarkets-302375648.html) | [[PR Newswire]] | | 1/21/2025 | [**Glooko Secures Reimbursement for Remote Monitoring of Gestational Diabetes in France**](https://www.prnewswire.com/news-releases/glooko-secures-reimbursement-for-remote-monitoring-of-gestational-diabetes-in-france-302356198.html) | [[PR Newswire]] | | 1/21/2025 | [**Glooko Secures Reimbursement for Remote Monitoring of Gestational Diabetes in France**](https://www.prnewswire.com/news-releases/glooko-secures-reimbursement-for-remote-monitoring-of-gestational-diabetes-in-france-302356192.html) | [[PR Newswire]] | | 1/3/2025 | [**Q&A: Philips on evolving care models, cybersecurity and digital health's future**](https://www.mobihealthnews.com/news/qa-philips-evolving-care-models-cybersecurity-and-digital-healths-future) | [[MobiHealthNews]] | | 12/23/2024 | [**Where 74 health system leaders are focused to prepare for 2025 - Becker's Hospital Review**](https://www.beckershospitalreview.com/hospital-management-administration/where-74-health-system-leaders-are-focused-to-prepare-for-2025.html) | [[Beckers Hospital Review]] | | 12/14/2024 | [**ICYMI: Highlights From COA 2024**](https://www.ajmc.com/view/icymi-highlights-from-coa-2024) | [[AJMC]] | | 12/13/2024 | [**Healthcare Revenue Cycle Management (RCM) Market Surges to USD 658.7 ... - PR Newswire**](https://www.prnewswire.com/news-releases/healthcare-revenue-cycle-management-rcm-market-surges-to-usd-658-7-billion-by-2030--propelled-by-24-cagr---verified-market-reports-302331323.html) | [[PR Newswire]] | | 12/12/2024 | [**How a Missouri system is building a 'winning culture'**](https://www.beckershospitalreview.com/hospital-management-administration/how-1-missouri-system-is-building-a-winning-culture.html) | [[Beckers Hospital Review]] | | 10/17/2024 | [**Healthcare Payer Services Business Research Report 2023-2024 & 2030 - Growth in Telehealth and Virtual Care Services Expands the Scope of Payer Services - ResearchAndMarkets.com**](http://www.businesswire.com/news/home/20241017425707/en/Healthcare-Payer-Services-Business-Research-Report-2023-2024-2030---Growth-in-Telehealth-and-Virtual-Care-Services-Expands-the-Scope-of-Payer-Services---ResearchAndMarkets.com/?feedref=JjAwJuNHiystnCoBq_hl-RLXHJgazfQJNuOVHefdHP-D8R-QU5o2AvY8bhI9uvWSD8DYIYv4TIC1g1u0AKcacnnViVjtb72bOP4-4nHK5ieT3WxPE8m_kWI77F87CseT) | [[Business Wire]] | | 10/17/2024 | [**Healthcare Payer Services Business Research Report 2023-2024 & 2030 - Growth in Telehealth and Virtual Care Services Expands the Scope of Payer Services - ResearchAndMarkets.com**](http://www.businesswire.com/news/home/20241017425707/en/Healthcare-Payer-Services-Business-Research-Report-2023-2024-2030---Growth-in-Telehealth-and-Virtual-Care-Services-Expands-the-Scope-of-Payer-Services---ResearchAndMarkets.com/?feedref=JjAwJuNHiystnCoBq_hl-Q-tiwWZwkcswR1UZtV7eGe24xL9TZOyQUMS3J72mJlQ7fxFuNFTHSunhvli30RlBNXya2izy9YOgHlBiZQk2LOzmn6JePCpHPCiYGaEx4DL1Rq8pNwkf3AarimpDzQGuQ==) | [[Business Wire]] | | 10/16/2024 | [**12 Compelling Sessions to Check Out at HLTH 2024 - MedCity News**](https://medcitynews.com/2024/10/12-compelling-sessions-to-check-out-at-hlth-2024/) | [[MedCity News]] | | 10/10/2024 | [**Healthcare Payer Services Business Research Report 2024: Global Market to Surpass $100 ...**](https://finance.yahoo.com/news/healthcare-payer-services-business-research-141400536.html) | [[Yahoo Finance]] | | 9/12/2024 | [**Financial Viability: Diversifying Revenue and Improving Payer Negotiations**](https://www.beckershospitalreview.com/strategy/financial-viability-diversifying-revenue-and-improving-payer-negotiations.html) | [[Beckers Hospital Review]] | | 7/1/2024 | [**North American Partners in Anesthesia (NAPA): New value-driven MSO/RCM services offer hospitals innovative solutions**](https://www.healthtechmagazines.com/north-american-partners-in-anesthesia-napa-new-value-driven-mso-rcm-services-offer-hospitals-innovative-solutions/) | [[Health Tech Magazines]] | ## Topic Overview (Some LLM-derived content — please confirm with above primary sources) ### Key Players - **Optum**: A healthcare services company that highlights reimbursement challenges faced by health systems. - **Mayo Clinic**: A leading healthcare provider exploring home-based treatment options for cancer patients, emphasizing the need for reimbursement solutions. - **Centers for Medicare & Medicaid Services (CMS)**: A key player in determining reimbursement policies for healthcare services, including AI technologies. - **Centers for Medicare and Medicaid Services (CMS)**: The U.S. federal agency that oversees Medicare and Medicaid programs, involved in reimbursement policies. - **Anthem Blue Cross Blue Shield**: A major health insurance provider that reversed a controversial update to its anesthesia reimbursement policy. - **Unite Us**: A technology provider that enhances reimbursement processes for community organizations, particularly in rural healthcare. - **American Hospital Association (AHA)**: An organization that criticized the Pay PCPs Act for potentially leading to payment cuts for providers. - **HealthArc**: A unified remote care management platform that optimizes reimbursements and streamlines workflows in remote care programs. - **Brellium**: A startup developing AI-powered solutions to automate clinical quality and payer compliance, addressing documentation gaps that impact reimbursement. - **Cardinal Health**: A major player in the healthcare providers and services sector, facing challenges like high operational costs and reimbursement pressures. - **UnitedHealth Group**: A health insurance company facing scrutiny over its acquisition of Amedisys due to market competition concerns. - **Arintra**: A technology company that automates medical coding to improve claims accuracy and revenue cycle performance. - **Nym**: A startup focused on automating medical coding using machine learning to improve efficiency in billing and reimbursement. - **Certified Community Behavioral Health Clinics (CCBHCs)**: Organizations that provide comprehensive mental health and substance use services, facing challenges with stagnant Medicaid reimbursement rates. - **Glooko, Inc.**: A digital health company that provides solutions for diabetes management and has received reimbursement approval for remote monitoring. - **Iodine Software**: A company focused on automating appeals management and improving revenue capture for healthcare organizations. - **FrontRunnerHC**: A healthcare data automation platform that enhances patient registration and billing processes. ### Partnerships and Collaborations - **Unite Us and Missouri HealthNet**: Collaboration to integrate a revenue cycle management solution that streamlines reimbursements for community organizations. - **Mayo Clinic and Memorial Sloan Kettering**: Collaborating on home-based cancer treatment programs, addressing reimbursement and regulatory challenges. - **University of Pennsylvania Health System and Independence Blue Cross**: Established a long-term agreement on reimbursement rates effective July 1, 2025. - **Digital Medicine Society (DiMe)**: Collaborates with industry partners to advance the digitization of healthcare and improve reimbursement practices. - **Iodine Software**: Developing partnerships to enhance clinical documentation and appeals management solutions. - **Advocate Health and Medicare Shared Savings Program**: Advocate Health achieved significant savings through participation in value-based care initiatives, emphasizing collaboration for improved patient outcomes. - **Community Oncology Alliance (COA) and Primary Care Providers**: COA emphasizes the need for partnerships to enhance patient outcomes and address reimbursement concerns in oncology. - **HealthArc and athenahealth**: HealthArc integrates its remote care management platform with athenahealth's EHR to enhance clinical documentation and patient engagement. - **Commure and Memora Health**: Commure acquired Memora Health to enhance AI-driven automation capabilities in clinical workflows. - **FrontRunnerHC and athenahealth**: This partnership integrates FrontRunnerHC's healthcare data automation platform into athenahealth's Marketplace program to improve patient registration and billing processes. - **Advancing Digital Health Coalition**: A merger between the American Telemedicine Association's advocacy arm and the Digital Therapeutics Alliance aimed at promoting digital health technologies and addressing reimbursement challenges. - **PsychArmor and CareSource**: Partnering to enhance employee training for better support of veterans and military families. - **Providence and Xsolis**: Providence expands its partnership with Xsolis to enhance healthcare operations through AI-driven technology. - **Future Leaders Awards Program**: In partnership with Homecare Homebase, this program recognizes emerging professionals in various healthcare sectors. ### Innovations, Trends, and Initiatives - **Anesthesia Coverage Solutions**: Proposals for equitable reimbursement models for anesthesia services across all payers to improve recruitment and operational efficiency in Ambulatory Surgery Centers. - **Remote Patient Monitoring (RPM)**: Despite its potential, RPM faces reimbursement challenges that hinder its adoption, particularly in Medicaid, necessitating standardized policies. - **Home Health Initiatives**: Programs like the Acute Hospital Care at Home by CMS are facilitating reimbursement for home-based acute care. - **Changes in RPM Reimbursement Requirements**: CMS has removed the requirement for RPM providers to collect data for at least 16 of 30 days to qualify for Medicare reimbursement, effective 2026. - **Telehealth and Remote Monitoring**: The rise of telehealth services and remote monitoring technologies is reshaping care delivery and reimbursement opportunities. - **PC Flex Model**: A new reimbursement model set to launch in 2025, promoting health equity by integrating primary care with behavioral health services. - **Telehealth Adoption**: Despite a decline in usage post-pandemic, telehealth remains crucial for enhancing access to care, with advocates pushing for better reimbursement models. - **Digital Health Policy Initiatives**: Discussions at CES 2025 highlighted the need for comprehensive policies to support digital health innovations, including reimbursement for new technologies. - **AI in Revenue Cycle Management**: Innovations in AI are enhancing operational efficiency and financial accuracy in healthcare settings, with a focus on automated financial clearance and fraud detection. - **AI Integration**: AI technologies are being integrated into healthcare to improve patient outcomes and streamline reimbursement processes. - **AI in Medical Coding**: Nym's technology automates medical coding, addressing inefficiencies in manual practices and supporting reimbursement processes. - **AI in Medical Billing**: Advancements in AI are transforming medical billing by reducing time for billing tasks and minimizing human error, adapting to the shift from fee-for-service to value-based billing. - **Value-Based Care (VBC)**: A model that emphasizes preventive care and wellness, requiring payers to adopt comprehensive contract management and payment systems prioritizing quality over quantity. - **Digital Therapeutics (DTx)**: Expected to gain traction, particularly in mental health, with new reimbursement codes from CMS enhancing credibility and adoption. - **Real-World Evidence (RWE) Solutions**: The market is expanding due to the shift towards personalized and value-based healthcare, with a focus on comprehensive patient outcome insights. - **AI Agents by Thoughtful AI**: Introduction of AI agents designed to automate claims processing, patient eligibility verification, and payment posting to improve efficiency in revenue cycle management. - **Clinical Documentation Integrity (CDI)**: Evolving from a cost center to a strategic asset, CDI programs enhance financial performance and care quality through accurate clinical documentation. - **AI in Healthcare**: Ongoing advancements in AI are expected to transform healthcare risk adjustment and improve efficiency in managing risk scores. ### Challenges and Concerns - **Reimbursement Uncertainties in Telehealth**: Providers are scaling back virtual care offerings due to uncertainties surrounding reimbursement policies post-COVID-19. - **Inconsistent Reimbursement Models**: Digital therapeutics face challenges due to inconsistent reimbursement models, prompting advocacy for wider acceptance. - **Reimbursement Rates**: Healthcare providers face declining reimbursement rates, particularly in skilled nursing and gastroenterology, impacting financial sustainability. - **Stagnant Reimbursement Rates**: Behavioral health organizations face financial sustainability challenges due to stagnant Medicaid reimbursement rates and rising operational costs. - **Reimbursement Uncertainties**: Ongoing uncertainties in reimbursement policies for telehealth and AI technologies pose significant barriers to their widespread adoption. - **Claims Denials and Prior Authorization**: Significant issues in the healthcare finance sector leading some providers to stop accepting Medicare Advantage reimbursements due to high denial rates. - **Reimbursement Disparities**: Small Ambulatory Surgery Centers (ASCs) face significant challenges due to rising operational costs and insufficient insurance payments, threatening their viability. - **Reimbursement for Telehealth**: Healthcare providers are hesitant to adopt telehealth fully without adequate reimbursement, despite its long-term benefits. - **Regulatory Changes**: Ongoing regulatory changes are complicating reimbursement processes and impacting the financial viability of healthcare providers. - **Reimbursement Disparities in ASCs**: Ambulatory Surgery Centers (ASCs) are experiencing reimbursement disparities compared to hospital outpatient departments, impacting their financial viability. - **Administrative Burdens**: Physicians report administrative work and reimbursement issues as top concerns, impacting their practice and income. - **Limited Reimbursement Pathways for AI**: Despite the FDA approving numerous AI-enabled medical devices, reimbursement pathways remain limited, hindering widespread adoption in clinical settings. - **Regulatory Pressures**: Increased regulatory requirements and scrutiny over the use of AI in care denial processes raise concerns about reimbursement practices. - **Slow Transition to Value-Based Care**: Healthcare providers are struggling with the transition from fee-for-service to value-based care models, complicating reimbursement processes. - **Regulatory Complexities**: The evolving nature of regulations surrounding AI and digital health technologies adds layers of complexity to reimbursement strategies. - **Medicare Advantage Denials**: A significant surge in denials from Medicare Advantage plans is creating additional reimbursement challenges for health systems. - **Workforce Shortages**: Healthcare organizations are facing staffing challenges that complicate reimbursement processes and financial stability. - **Low Collection Rates**: Healthcare organizations are struggling with low collection rates and high denial rates in revenue cycle management, impacting financial stability. - **Operational Efficiencies**: Healthcare organizations must navigate operational challenges and implement innovative strategies to maintain healthy margins amid lower reimbursements. ## Related Topics [[Reimbursement Policies]]; [[Reimbursement Rates]]; [[Reimbursement Cuts]]; [[Reimbursement Models]]