Cincinnati-based revenue cycle managment company Ensemble says that former HCA Healthcare CFO Bill Rutherford has joined its board of managers. Rutherford recently retired from HCA Healthcare after 34 years. During his tenure, he oversaw financial operations including the Treasury Department, Office of the Controller, Information Technology, Government Programs, Strategic Resource Group and Revenue Cycle Operations. Rutherford joins a board that includes Jane Moran, CIO at Mass General Brigham.
Rep. Timothy Reeder (R-Ayden), an emergency room physician from Pitt County, said that reforming the prior authorization process in the state will be at the top of his legislative agenda. Reeder co-sponsored a bill to improve prior authorization during the 2023-24 legislative session.
According to a 2023 survey by the American Medical Association, 94% physicians indicated that prior authorization, the process by which physicians are required to receive health insurance companies’ approval before providing medical service, had delayed their patients’ care. Of the 1,000 physicians surveyed, 24% reported that prior authorization delays caused direct harm to patients.
A Virginia hospital is facing federal criminal charges over what prosecutors say was an extended scheme to profit from a high-billing doctor's troubling practices, including dozens of medically unnecessary surgeries performed on unsuspecting women, which left some of them sterile.
An indictment filed Wednesday in federal district court in Norfolk charges the hospital, Chesapeake Regional Healthcare, with healthcare fraud and conspiracy to defraud the United States. The hospital collected about $18.5 million in reimbursements from private insurers, Medicare and Medicaid for questionable procedures performed between 2010 and 2019 by Javaid Perwaiz, prosecutors say. The obstetrician-gynecologist was sentenced to 59 years in prison for abusing female patients with unnecessary surgeries to enrich himself with insurance payouts.
In a statement Wednesday, the hospital called the allegations from federal prosecutors "unfounded and an excessive overreach." "Chesapeake Regional is dedicated to patient safety, prioritizing high-quality care that meets rigorous national standards," it said.
Federal law requires that all nonprofit hospitals have financial assistance policies to reduce or expunge people's medical bills.
New research from Dollar For, an organization dedicated to helping people get access to charity care, suggests that fewer than one-third of people who qualify for charity care actually receive it.
What are the tangible ways AI can make this process easier? The most obvious improvement is in the claims scrubbing process, something historically managed by clearinghouses—a tool that allows providers to easily send batches of electronic claims to different insurance payers at once. Clearinghouses reject malformed claims before they get sent to payers based on certain universal rules, which include formatting issues, incorrect use/combinations of codes or conflicting insurance information. Using payer policies as ground truth and learning from every denial, AI tools can create a comprehensive rule engine for each individual payer so that no claim is denied for the same reason as another, taking the onus off the biller to read and remember policies, which are often unnecessarily complex and constantly changing. Then, with access to the EMR, AI could automatically resubmit a corrected claim, or flag the issue if information is missing. Eventually, a billing team would no longer be necessary—the rules engine would allow the AI to build the claim correctly on its own.
