Insights

Harnessing the Power of Payer Litigation to Empower Revenue Recovery
Revenue Recovery
admin

Harnessing the Power of Payer Litigation to Empower Revenue Recovery

Harnessing the Power of Payer Litigation to Empower Revenue Recovery Payer litigation is becoming a potent force as healthcare providers increasingly stand up against health insurance payers to demand fair compensation for their vital services. In this blog, we delve into impactful lawsuits, highlighting the need for accountability and how Allia Group empowers healthcare providers in their fight for revenue recovery. 1. Arkansas ASCs Demand Fair Reimbursement Little Rock ASCs, Freeway Surgery Center, and Centerview Surgery Center, are seeking millions in unpaid reimbursements from Arkansas Blue Cross and Blue Shield. Despite serving as temporary hospitals during the pandemic, these ASCs claim they weren’t properly reimbursed at hospital rates. Lawsuits against insurers should persist until fair reimbursement is ensured for all providers. Read about the Arkansas ASCs lawsuit on Becker’s Payer 2. Healthcare Justice Coalition vs. UnitedHealth Group The Healthcare Justice Coalition (HJC) takes legal action against UnitedHealth Group, seeking over $2.5 million in damages for the underpayment of emergency physicians. The lawsuit highlights the threat to healthcare stability and advocates for fair compensation. Systemic underpayments jeopardize emergency physician groups and impact patient care. Allia Group supports the pursuit of justice for under-reimbursed healthcare providers. Learn more about the HJC lawsuit 3. Arizona Healthcare Groups Challenge BCBS In Arizona, a legal battle unfolds as healthcare groups representing over 300 doctors take on BCBS, the state’s largest medical insurer. Allegations include pressuring providers into accepting lower reimbursements and paying terminated contracts as if they were still in-network. The lawsuit seeks justice against unfair practices, emphasizing the importance of legal action to halt problematic behavior from insurers. Discover more about the Arizona lawsuit in the comments section 4. Cigna’s $172.3 Million Settlement Litigation works! Cigna faces accountability for fraudulent behavior, agreeing to disperse $172.3 million to settle False Claims Act violation accusations. The payer allegedly submitted incorrect Medicare Advantage patient data to secure higher payments. This case underscores litigation’s power against payers. Explore Cigna’s settlement details Empower Your Revenue Recovery with Allia Group Healthcare providers, don’t let unfair reimbursement practices hinder your financial stability. Explore how Allia Group’s bundled case model and litigation finance platform can assist you in recovering withheld revenue and contact us for a consultation

Read More »
AI Lawsuits: Unraveling the Legal Action and Impact of AI on Health Insurance Claims
Revenue Recovery
admin

AI Lawsuits: Unraveling the Legal Action and Impact of AI on Health Insurance Claims

Algorithm Lawsuits: Unraveling the Impact of AI on Health Insurance Claims In recent legal battles, health insurance payers face scrutiny for the misuse of artificial intelligence (AI) tools, sparking lawsuits and raising concerns about fair claims processing. 1. Humana Faces Legal Action Over nHPredict AI Tool Humana is now embroiled in a lawsuit filed in the U.S. District Court for the Western District of Kentucky, accusing the insurer of using the nHPredict AI tool to wrongfully deny Medicare Advantage claims. This adds to the growing number of cases against major insurers for their alleged misuse of automated data tools. Read more about the latest AI lawsuit 2. UnitedHealthcare’s Alleged Misuse of nH Predict AI Model UnitedHealthcare faces allegations of using the “nH Predict” AI model with a reported 90% error rate to deny health coverage, resulting in premature discharges and financial burden on patients. The lawsuit filed in Minnesota claims breach of contract, unjust enrichment, and insurance law violations, seeking damages and an end to AI-based claims denials. Learn more about the UnitedHealthcare lawsuit 3. AI Impact on Medicare Patients’ Rehab Care UnitedHealth’s AI algorithm allegedly influences decisions to cut off Medicare patients’ rehab care, prioritizing cost-cutting over patient well-being. The algorithm guides decisions, and employees are penalized for deviating from its determinations. This narrative challenges the healthcare giant’s commitment to patient care and raises questions about the ethical use of AI in healthcare. Watch the video for a compelling discussion on the lawsuit 4. Cigna Faces Lawsuits Over Automated Mass Claims Denials Cigna is under fire for automated mass claims denials, facing lawsuits from a Minnesota member and a shareholder in Delaware. The complaints allege automatic coverage denials due to the PxDx tool, leading to medical bills sent to collections. As these lawsuits unfold, they shed light on the potential mismanagement and breaches of fiduciary duty, prompting further investigations. Explore the latest allegations against Cigna Stay informed about the evolving landscape of AI in health insurance and the legal challenges reshaping the industry. It’s important to ensure insurers are playing fair and held accountable for potential misdeeds – and litigation is a powerful way to ensure payers are held accountable.

Read More »
Solving Revenue Recovery Challenges Faced by Ambulance Services
Revenue Recovery
admin

Solving Revenue Recovery Challenges Faced by Ambulance Services

Solving Revenue Recovery Challenges Faced by Ambulance Services Emergency services, particularly ambulance providers, are grappling with a dire financial situation, exposing vulnerabilities in the current economic model. The broken system puts essential services at risk, exemplified by Berkshire County’s ambulance service facing a funding crisis due to reimbursement and insurance challenges. 1. Reimbursement Struggles: A Ticking Time Bomb The broken economic model has led to reimbursement challenges for ambulance services, where private insurers are falling short on their financial obligations. Brian Andrews, president of County Ambulance, shed light on the exploitative practices of some carriers negotiating reduced reimbursements. Timely payments and sufficient coverage are vital, and without them, ambulance services may struggle to maintain response times and quality care. Read more about Berkshire County’s funding crisis 2. Proposals to Combat Out-of-Network Bills A government advisory committee proposes capping emergency ambulance ride costs at $100 to address out-of-network billing issues. With over 50% of insured patients at risk of receiving out-of-network bills, the committee suggests a payment system to create more predictable rates. Ambulance providers and insurers would enter a rate-setting arrangement, aiming to eliminate surprise billing and create fair compensation for services. Explore the proposed solutions 3. Out-of-Network Challenges in Ground Ambulance Rides In 2022, a majority of ground ambulance rides were out-of-network, leaving patients with limited provider choices and no federal protection from surprise billing. The limitations of Independent Dispute Resolution (IDR) in these instances, coupled with potential pushouts from health insurance carriers, underscore the need for ambulance providers to regain control and explore litigation strategies. Read the report Allia Group Helps Ambulance Services Recover Revenue In the face of these challenges, Allia Group offers a unique business model tailored for ambulance providers. Increase revenue directly from insurance underpayments without patient-focused collection efforts. Explore our services here and reach out to start the conversation.

Read More »
denial claims process
Uncategorized
admin

New Ways to Deny Care: AI’s Transformation of the Claims Denial Process

New Ways to Deny Care: AI’s Transformation of the Claims Denial Process Artificial Intelligence (AI) has become a powerful tool in various industries, including healthcare and insurance. However, its implementation is not without controversy. In recent news, big insurance companies are facing scrutiny for their use of AI in questionable practices. Cigna, a prominent insurance company, has recently come under fire for its reported claims process, raising concerns about patient access to necessary care and treatments. The use of algorithms and AI to approve or deny claims without proper evaluation has sparked outrage, prompting insurance commissioners and federal lawmakers to take action. In this blog, we will delve into the issues surrounding Cigna’s practices, the concerns raised by federal lawmakers, the need for regulation, and the advocacy efforts to ensure fair and ethical AI use in the healthcare industry. Cigna Comes Under Fire Cigna recently came under fire for its reported claims process. According to an investigation by ProPublica and NPR, Cigna has been denying claims without even reading them first. This means that many patients have been denied access to necessary care and treatments without even having their claims properly evaluated. Insurance commissioners across the country are taking notice of this irresponsible behavior and attempting to hold Cigna accountable. Cited is a violation of their fiduciary duty as justification for stronger regulations against them. “If these figures are at all illustrative of Cigna’s commercial appeal and reversal rates, it would suggest that the PXDX review process is leading to policyholders paying out of pocket for medical care that should be covered under their health insurance contract,” rep. Cathy McMorris Rodgers said in a letter to Cigna. Ultimately, Cigna’s use of AI to approve or, more likely, deny claims, is just another draconian example of healthcare insurers putting profits before people – denying claims without even looking into them is utterly unacceptable. This is one big reason federal lawmakers continue to raise concerns about insurers’ use of algorithms and AI to approve or deny claims.  Federal Lawmakers Raise Concerns Sen. Ron Wyden voiced his concerns in a June 8 Senate Finance Committee hearing, saying he is “increasingly concerned by the potential for abuse when it comes to the use of big data and algorithms in healthcare.”  “If insurance companies are getting bigger, and buying companies that specialize in developing algorithms, it strikes me that they are going to be in a position to invest in new ways to deny care,” Mr. Wyden said. “That strikes me as a prescription for trouble.”  There needs to be more oversight and regulation of algorithms to approve and deny claims. However, as with most AI-related discussions, this technology comes down to user intent. Karen Joynt Maddox, MD, associate professor of medicine at Washington University in St. Louis, commented: “We should figure out how to harness the algorithms for good rather than evil…because it’s being done in an unregulated and unknown manner, we’re seeing people get out ahead who are in the business of trying to deny care.” What’s next for AI in healthcare? Hopefully, proper regulation. Advocacy Efforts The AMA will advocate for greater regulatory oversight of AI use by health insurance companies. In fact, seven national specialty societies introduced a resolution at the 2023 AMA Annual meeting. According to the AMA, “The question raised by such use of technology is whether its use is in compliance with the state and federal insurance regulations that govern payer decision-making on whether to approve claims or prior-authorization requests.” No doubt, there is a need for further policy on the use of AI in healthcare given its quick evolution and adoption. We support the AMA’s policies and advocacy to guide the proper and fair use of AI in healthcare. Has your revenue cycle been impacted by claims denials? Allia Group can help recover lost revenue in other places. Contact us to learn more about our unique litigation model to recover underpayments for out-of-network care.

Read More »
Skip to content