Premier Medical Appeals

Premier Medical Appeals Premier Medical Appeals seeks to partner with hospitals, physicians and other healthcare providers to safeguard revenue.

We recognize that the profit margin for the healthcare provider has contracted and that every reimbursement is important. Premier Medical Appeals has an experienced staff of highly trained clinical personnel. This team is capable of navigating the unique and often complex payer requirements that must be met in order to receive reimbursement for services. Our expertise is in developing an appeal response to all types of payer denials.

10/23/2025

Bloomberg (10/21, Tozzi, Subscription Publication) reports UnitedHealth Group is “testing a new system to streamline how medical claims are processed, an early example of what the company says is the potential for artificial intelligence to smooth out friction in billing. The system, dubbed Optum Real, aims to distill health plans’ complex rules around what is covered into information that doctors and billing staff can use in real time to tell whether a claim is likely to be paid.” The system has been used “at Allina Health, a 12-hospital system based in Minneapolis, since March, where two departments have used it to connect to UnitedHealthcare, the health conglomerate’s insurance division. It’s already reduced claims denials meaningfully across more than 5,000 visits in Allina’s outpatient cardiology and radiology departments, said Dave Ingham, chief digital and information officer for the hospital group.”

10/03/2025

Bloomberg Law (10/2, Belloni, Subscription Publication) reports that rural hospitals “facing financial headwinds and frustrated with prior authorization demands are withdrawing from contracts with Medicare Advantage plans, prompting concerns from insurers that the cancellations could have consequences for patients.” According to Bloomberg Law, “over 25 hospitals across the country have decided to pull out of some or all of their Medicare Advantage contracts since Jan. 1. Industry groups such as the American Hospital Association cite MA’s lower reimbursement, more aggressive prior authorization, and increased administrative demands when compared with traditional Medicare as reasons behind the contract closures.” Most of the cancellations “have come from Medicare Advantage plans from large national insurance firms such as Anthem Blue Cross Blue Shield, Aetna, Humana, and UnitedHealthcare.”

09/27/2025

Forbes (9/25, Japsen) reports an analysis by the Urban Institute estimates that “hospitals, physicians and other medical care providers will lose more than $32 billion in revenue next year” if Congress “doesn’t extend tax credits for those with individual coverage under the Affordable Care Act.” In addition to the billions in lost revenue in 2026, “hospitals would also see a $7.7 billion increase in ‘uncompensated care,’ which are services these medical care providers must deliver but aren’t reimbursed for by government and private insurers, the Urban Institute report said.”

08/15/2025

Healthcare Finance News (8/13, Lagasse) says a new report found that 88% of “health systems are using artificial intelligence internally, but just 18% have a mature governance structure and fully formed AI strategy.” Analysts at the Healthcare Financial Management Association and market research company Eliciting Insights noted that “governance is lacking despite the fact that 71% of survey respondents have identified and deployed pilot or full AI solutions in finance, revenue cycle management or clinical functional areas.” According to the report, “nearly 80% of health systems say an existing vendor, or a firm partnered with an existing vendor, would have a significant advantage over a new vendor looking to pilot AI. And 70% of health systems say they would be more comfortable sharing data to power AI models with existing vendor partners.”

08/13/2025

KFF Health News (8/12, Zionts) reports, “Emergency medicine researchers and providers believe ERs, especially in rural areas, increasingly operate with few or no physicians amid a nationwide shortage of doctors.” One study published in JACEP Open “found that in 2022, at least 7.4% of emergency departments across the U.S. did not have an attending physician on-site 24/7.” Over “90% were in low-volume or critical access hospitals – a federal designation for small, rural hospitals.” Some physicians “and their professional associations say physicians’ extensive training leads to better care, and that some hospitals are just trying to save money by not employing them.”

06/10/2025

Today, an American Medical Association-affiliated panel will convene a listening session around a potential new category of billing code for artificial intelligence products.
In 2024, the AMA's independent CPT Editorial Panel — which maintains the set of codes used by providers for billing and have a huge influence on reimbursement — formed a Digital Medicine Coding Committee (DMCC) to advise the panel on coding for tech, including AI. The committee is considering a new category of code for algorithms that crunch patient data into outputs that are used for making decisions about clinical care. Tentatively called "Clinically Meaningful Algorithmic Analyses," the new category would group AI tools in a single place in the CPT code set. Over the last few years, the CPT panel developed a taxonomy of AI services, and this year, four codes were added for "AI augmentative data analysis" used in procedures including electrocardiogram measurement and image-guided prostate biopsy.
Today's DMCC meeting is the second of two on the calendar, and it seems you can still register to attend, though you must abide by the AMA's confidentiality policy. A source told me it's possible we'll see a code change application for the algorithmic analyses at the September meeting of the CPT Editorial Panel. In other words, it is correct to view all this talk as a precursor to real action. Interestingly, the DMCC's membership is not posted online in any obvious way.

04/30/2025

Reuters Legal (4/29, Novak Jones) reports the U.S. Supreme Court issued a 7-2 opinion Tuesday siding with “the U.S. Department of Health and Human Services in a lawsuit brought by more than 200 hospitals that serve low-income populations that had challenged the government’s method of determining the hospitals’ compensation.” The case focused on “how to reimburse hospitals for care provided to low-income patients.” In the opinion authored by Justice Amy Coney Barrett, “the majority held that HHS’ method of determining when to provide additional Medicare reimbursement to hospitals that serve disproportionately low-income populations was in line with Congress’ intent.” According to the court, “Congress’ language in the statute governing how to adjust reimbursement rates made clear that the patient has to receive a payment from a certain federal assistance program – not just be eligible for it – to be counted.”

04/14/2025

Modern Healthcare (4/11, Early, Subscription Publication) reported CMS published a proposed rule Friday indicating “Medicare reimbursements for inpatient hospital care would increase 2.4% in fiscal 2026.” Going forward, “long-term care hospitals would get a 2.6% pay hike under the same draft regulation. A separate rule issued Friday calls for a 2.4% boost to inpatient psychiatric facility rates next fiscal year, which begins Oct. 1.” The proposed update “reflects a 3.2% increase in the market basket used to calculate rates, minus a productivity adjustment.” In a news release, the Federation of American Hospitals criticized the reimbursement increase as insufficient. Meanwhile, CMS is seeking industry input “on how it could improve digital quality measurement as the sector transitions to electronic clinical quality measures.”

03/10/2025

Forbes (3/9, Japsen) reports that the American Medical Association (AMA) and various physician groups raised concern over a recent decision by Congress to implement a 2.8% cut in Medicare payments to physicians. This decision emerged from a funding bill released over the weekend. AMA President Bruce Scott, MD, stated that the cuts are “particularly devastating for rural and underserved communities,” where “physicians and their patients have borne the brunt of the rising practice costs.” The AMA had previously supported bipartisan legislation to halt the cuts plus provide “a 2% payment update to help offset the rising costs of running a practice.” Scott said, “Despite repeated warnings, lawmakers are once again ignoring the dire consequences of these cuts and their impact both on patients and the private practices struggling to keep their doors open.”

01/13/2025

Health care AI systems require consistent monitoring, staffing to keep them working well
KFF Health News (1/10, Tahir) reported, “Algorithm glitches are one facet of a dilemma that computer scientists and doctors have long acknowledged but that is starting to puzzle hospital executives and researchers: Artificial intelligence systems require consistent monitoring and staffing to put in place and to keep them working well. In essence: You need people, and more machines, to make sure the new tools don’t mess up.” Government officials are concerned that “hospitals lack the resources to put these technologies through their paces.” According to KFF Health News, “evaluating whether these products work is challenging,” but “evaluating whether they continue to work...is even trickier.”

10/25/2024

CBS News (10/24, Picchi) says, “Medicare Advantage plans reaped $4.2 billion in extra payments last year by making home visits to senior citizens who may not have received treatment for serious health issues, a new government report has found.” The report (PDF), which was issued by HHS-OIG, “flags concerns with so-called health risk assessments, or HRAs, which are home visits used to diagnose Medicare enrollees for serious health issues.” Because older people “who suffer from major health issues can trigger higher risk-adjusted payments for Medicare Advantage plans, the agency wanted to determine whether these HRAs are misused.” The report “said UnitedHealthcare collected $3.7 billion of risk-adjusted payments last year, making it the biggest benefactor of the practice, followed by Humana, with $1.7 billion.”

This practice should be investigated thoroughly as it has the potential for massive fraud and may be making more money unnecessarily.

10/01/2024

Healthcare Finance News (9/30, Lagasse) reports, “Health care claims processing is rife with inefficiencies and financial strains marked by operational bottlenecks, rising denial rates, and increasing administrative burdens faced by providers, according to the new State of Claims 2024 report [PDF] from Experian, a data analytics and consumer credit reporting company.” Among the important “trends is the rising rate of claims denials across the health care sector.” Rates of claims denials “have steadily increased, with providers seeing rejection rates as high as 10 to 15%.” The company “attributes this increase to several factors, including tighter regulatory scrutiny, complex billing requirements, and payer policies that are continuously evolving.”

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