In an HHS-OIG review of June 2024 data, Medicare Advantage plans overturned 95% of appealed SNF admission denials, while enrollees and providers appealed 18% of denials. What that gap means for post-acute appeal triage.
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Federal deregulation is narrowing AI transparency rules in certified health IT. It doesn’t remove the need to show how an AI-influenced decision was made. What certification, accreditation, and payer contracts actually require in 2026.
SNF admissions leaders make referral decisions in minutes, on an incomplete financial picture, while Medicaid — their primary payer — keeps getting squeezed. Here’s why that’s an architecture problem, not a training problem, and what it would take to fix it without asking facilities to spend money they don’t have. Table of contents The twenty-minute […]
Short answer: CMS-0057-F requires health plans to launch a Prior Authorization API by January 1, 2027. As of WEDI’s most recent survey, a large share of payers are still early in that build, even as many announce broader prior-auth reform. For hospitals — especially rural and critical access hospitals in the Pacific Northwest running on […]
It’s 4:40 p.m. on a Thursday. An admissions coordinator has four referral packets open in four tabs, a hospital case manager on hold, and one open bed. Somewhere in those four PDFs is a patient whose medications alone could run more than the bed is worth. Nobody has time to find out which one before […]
In this article The regulatory stack got real Why “we have a committee” isn’t the answer What actually holds up Ask a room of hospital CIOs whether their organization “has AI governance” and almost everyone nods. Ask what happens the day an auditor asks for the decision trail behind one specific AI-flagged denial, and the […]