Cost of Health Care

24 Sep

Posted at 14:51h in Insurance, Medicare

By Lara Goulson, licensed independent insurance agent, Goulson Insurance Services, Los Angeles

Medicare Advantage enrollment has crossed half of all Medicare beneficiaries nationally, and the marketing that accompanies it has converged on a single number: the monthly premium. In a large competitive county that number is usually zero, which means it carries almost no information. The figure that actually determines financial exposure in a bad year is a different one. It is published, and almost nobody looks at it. According to CMS (Centers for Medicare and Medicaid Services), every Medicare Advantage plan is required to publish an annual in-network out-of-pocket maximum — the figure that defines a member's worst-case financial exposure in a given year — yet this number is rarely the focus of plan marketing or consumer decision-making.

[caption id="attachment_76226" align="aligncenter" width="500"]Photo by Pixabay: https://www.pexels.com/photo/close-up-photo-of-a-stethoscope-40568/ Photo by Pixabay: https://www.pexels.com/photo/close-up-photo-of-a-stethoscope-40568/[/caption]

21 Sep

Posted at 18:07h in Cost of Health Care, Medicare

Closing in on retirement? Congratulations are in order. This year, around 4.2 million people in the U.S. will turn 65, joining the ranks of those approaching retirement. Retirement signals a move away from the daily grind of work and into a new chapter filled with more freedom. This transition is exciting, but it also comes with important financial considerations. After all, you're shifting from a steady paycheck to savings, investments, and benefits. You'll want to make sure your income lasts, your healthcare needs are covered, and your lifestyle remains comfortable well into the future. According to the IRS (Internal Revenue Service), the rules governing when and how retirement account withdrawals are taxed differ significantly depending on the account type — making withdrawal sequencing one of the most consequential financial decisions retirees face.

https://images.pexels.com/photos/8441812/pexels-photo-8441812.jpeg Pexels

18 Sep

Posted at 21:06h in Medical Billing

MIPS reporting determines part of your Medicare Part B payment adjustment two years out. The data your practice submits for 2026 sets your 2028 reimbursement rate. Practices that treat this as a first-quarter paperwork task often miss that timing. CMS (Centers for Medicare and Medicaid Services) scores four categories: Quality at 30 percent, Cost at 30 percent, Promoting Interoperability at 25 percent, and Improvement Activities at 15 percent. The performance threshold is 75 points. Falling short triggers a penalty of up to 9 percent on Medicare claims. For 2026, CMS expanded MIPS Value Pathways from 21 to 27, adding podiatry, pathology, and four other specialties. Multispecialty groups also lost the option to report an MVP at the group level unless they qualify as a small practice.

[caption id="attachment_76121" align="aligncenter" width="500"]Photo by Tima Miroshnichenko: https://www.pexels.com/photo/side-view-of-a-woman-8376317/ Photo by Tima Miroshnichenko[/caption]

15 Sep

Posted at 17:28h in Medical Billing, OBGYNE

Almost every OBGYN practice runs a predictable schedule of prenatal visits, annual exams, ultrasounds, and surgeries. Behind all this is the billing team responsible for getting all those services paid. However, as a practice grows, the number of claims and, by extension, claim denials also increases. At this point, every small practice owner faces the same question: should they manage medical billing in-house, where the staff knows the providers and the patients, or should they outsource medical billing services for small practices so that specialists can help them scale at a faster rate? According to CMS (Centers for Medicare and Medicaid Services), accurate medical billing and coding are foundational to appropriate reimbursement, and errors in claims submission — whether from inexperience, staff turnover, or payer-specific rule gaps — represent one of the most common and preventable sources of revenue loss for small practices.

[caption id="attachment_76015" align="aligncenter" width="500"]medical-billing-obgyne-pexels.jpg Photo by Kindel Media[/caption]

11 Sep

Posted at 15:32h in Aging, Health and Wellness, Medicare

Navigating a Medicare Advantage plan can feel overwhelming. Between shifting provider networks, prior authorization rules, and confusing denial letters, many seniors simply do not know where to turn. That is exactly the gap patient advocates fill. The best patient advocate services combine licensed guidance, care coordination, and hands-on support to help older adults understand Medicare Advantage coverage, resolve billing disputes, and make informed treatment decisions. Leading providers include nonprofit organizations, state assistance programs, and private advocacy firms that specialize in Medicare patient advocate services for seniors who need clear answers about their benefits. According to CMS (Centers for Medicare and Medicaid Services), Medicare Advantage enrollees have the right to appeal coverage denials at multiple levels — but navigating those appeal deadlines and documentation requirements is where many seniors need the most help.

[caption id="attachment_75973" align="aligncenter" width="500"] Pexels[/caption]

06 Sep

Posted at 18:10h in Medicare

When Congress passed the Medicare Access and CHIP Reauthorization Act in 2015, it promised to fix something almost everyone in medicine hated: the Sustainable Growth Rate formula. SGR had a habit of threatening double-digit payment cuts to physicians almost every year, only for Congress to patch it at the last minute. MACRA killed that formula for good. In its place, it built a new system meant to tie Medicare Part B payments to performance rather than volume. That system, the Merit-based Incentive Payment System, started collecting real performance data in 2017. Physicians are now heading into roughly a decade of MIPS reporting history. That's long enough to ask a fair question: did the program do what it was supposed to do? According to CMS, MIPS is designed to shift Medicare payments from volume-based to value-based reimbursement, with adjustments applied to Medicare Part B claims two years after the performance period based on composite scores across four weighted categories.

[caption id="attachment_75901" align="aligncenter" width="500"]MACRA at Ten-pexels Photo by Vitaly Gariev[/caption]

19 Aug

Posted at 22:12h in Medical Billing

Medical practices need a steady money flow to stay open and serve patients well. Old paper methods slow down payments and create costly clerical mistakes. Digital tools step in to transform how practices handle billing from start to finish. Teams spend less time fixing denied claims and more time helping people. Clear software systems create smooth daily operations for medical offices of all sizes.

According to the Centers for Medicare & Medicaid Services, claims processing errors and delayed submissions remain among the leading causes of revenue loss for medical practices, making efficient billing systems a financial priority for practices of every size.

[caption id="attachment_75648" align="aligncenter" width="500"]Technology in Modern Revenue Cycle Management Photo by kaboompics:[/caption]

03 Aug

Posted at 19:27h in Cost of Health Care, Legal-Malpractice, Medical Billing

Unexpected hospital bills cause major financial stress for families across the country. When medical emergencies happen, care expenses grow quickly. Out of pocket costs can easily surpass standard health insurance coverage and drain personal savings. For patients facing constant calls from collection agencies and mounting bills, consulting a medical debt bankruptcy lawyer can offer a clear path toward financial recovery and peace of mind.

The challenges of managing unexpected healthcare costs — and the importance of building a realistic financial plan before costs become unmanageable — apply across many medical contexts, from emergency care to planned treatments. The same principles of budgeting, understanding coverage gaps, and knowing when to seek professional guidance explored in this overview of how to plan financially for major medical costs apply equally to families managing unexpected hospital debt.

[caption id="attachment_75411" align="aligncenter" width="500"]medical-debt-legal-help-pexels.jpg Photo by Nicola Barts[/caption]

28 Jul

Posted at 17:26h in Medicare

Turning 65 brings a lot of changes, and figuring out your health coverage shouldn't add to the stress. Medicare can feel confusing at first, especially with all the different parts, deadlines, and enrollment windows. But once you understand the basics, the process becomes much easier to manage.

This guide breaks down everything you need to know about getting started with Medicare. We'll cover the different parts of the program, how to enroll, and what happens if you miss a deadline. Whether you're approaching 65 or helping a parent navigate this process, you'll find clear, practical answers here. For a deeper look at how Medicare Advantage plans work in practice — including how to match a plan to your specific healthcare needs — see this guide to navigating Medicare Advantage plan selection.

medicare_enrollment_made_simple

27 Jul

Posted at 18:02h in Insurance, Medical Billing

Profitability in a medical practice is built long before a payment arrives. It starts with reliable patient information, correct coverage checks, complete documentation, clean coding, timely claims, and steady follow-up. When those steps stay organized, earned income reaches the practice with fewer delays. Leaders also gain clearer numbers on staffing, scheduling, equipment planning, and daily decisions that protect patient care while keeping margins healthy.

For a closer look at one of the most common sources of revenue leakage in this process — missed CPT codes and incomplete documentation — see this overview of how AI smart coding helps capture hidden revenue opportunities.

[caption id="attachment_75247" align="aligncenter" width="500"]revenue-cycle-management-pexels.jpg Photo by RDNE Stock project[/caption]

21 Jul

Posted at 19:12h in Electronic Records, Medical Billing

Proper medical coding ensures timely reimbursements, compliance, and financial sustainability. However, although healthcare is very structured, opportunities to bill for additional revenue are often missed because of limited CPT codes, missing documentation, and the continually evolving billing rules. With increasing detail in patient encounters and changes in coding rules, coding all services by hand is becoming increasingly difficult. Even when care is being provided, there can be revenue leakage due to missed procedures, lengthy service codes, billing of care coordination activities, and additional billing opportunities.

As the medical coding sector evolves to demand greater precision, uniformity, and efficiency, software for medical coding is becoming increasingly popular. AI is becoming an increasingly integral tool in finding coding opportunities that would likely be missed in vast amounts of clinical documentation, reconciling them to standards, and ensuring that full reimbursement is received. For context on how billing practices affect overall clinical operations, see this overview of how smart practices think about billing without losing focus on care.

[caption id="attachment_75136" align="aligncenter" width="500"]cpt-codes-you-are-missing Source: Freepik[/caption]

01 Jul

Posted at 10:22h in Cost of Health Care
Ever tried to find out how much a private medical appointment actually costs? Been a rip off for years. Non disclosed fees and ambiguous quotes. Price shopping depends on the clinic called. But things are changing fast. Patients expect transparent pricing before they book. Clinics who can't provide that are losing revenue. [caption id="attachment_74650" align="aligncenter" width="500"]transparancy-health-care-pricing Pexels[/caption] This trend is starting to impact consumer choices around care. It is particularly relevant to personalised women's health care. Trust is incredibly important in women's health. Transparency around fees, communication, and personalised care have been women's health patient demands for decades.

29 May

Posted at 20:00h in Medical Billing, Neurological Disorders
[caption id="attachment_74019" align="aligncenter" width="500"]neurology-medical-invoice.jpg Photo by Kindel Media[/caption] Medical billing errors affect an estimated 80% of hospital bills in the United States, according to a study published in the Journal of the American Medical Association. For neurological patients, the risk is even higher. Neurology involves a dense set of procedure codes, specialist fees, and payer-specific rules that create more opportunities for errors. Disputing a neurology bill is not the same as disputing a general medical charge. The procedures involved, electroencephalograms (EEGs), electromyography (EMG), nerve conduction studies, and brain imaging, each carry specific Current Procedural Terminology (CPT) codes. A single miscoded test can add hundreds of dollars to a patient's bill. This guide covers the most common neurology billing errors, how to read and challenge an itemized bill, and what New York patients specifically need to know about their legal rights. It also explains what proper neurology billing services look like from the provider side, and why that matters for what lands on your bill.

22 May

Posted at 10:55h in Electronic Records, Medical Billing
Medical records used to be paperwork. Now they're financial documents, legal documents, and increasingly, the difference between a healthy bottom line and a federal recoupment notice. Every diagnosis a clinician writes down feeds into a much larger system. Insurance reimbursement, federal payments, quality scores, and audit risk all flow from those notes. And the people reviewing them have gotten a lot more sophisticated.

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19 May

Posted at 19:17h in Medicare
[caption id="attachment_73847" align="aligncenter" width="500"]Houston Methodist Medicare Advantage Plan Photo by SHVETS production[/caption] If you live around Houston and you are getting close to 65, or you already have your red, white, and blue Medicare card in your wallet, you are probably asking one simple question: will my Medicare Advantage plan let me walk into a Houston Methodist building and use my benefits without a problem? The short answer is usually yes, but you have to pick the right carrier. The longer answer is what this post is for. Let's go through it together, slow and clear, with none of the insurance jargon that makes your eyes glaze over.

About Houston Methodist

Houston Methodist runs a big footprint in the city. They have a main campus inside the Texas Medical Center, and they keep community hospitals out in places like The Woodlands, Sugar Land, Willowbrook, Clear Lake, Baytown, and West Houston. They also have a Continuing Care unit, plus a long list of smaller clinics and physician offices around town. The reason people care so much about which Medicare plan works there is simple — the system has a strong name, and many seniors want their cardiologist, surgeon, or cancer doctor to sit somewhere inside that group.

12 May

Posted at 15:23h in Medicare, Radiology
[caption id="attachment_73691" align="aligncenter" width="500"]does-medicare-pay-for-echocardiogram.jpg Photo by Los Muertos Crew[/caption] If your doctor just ordered an echocardiogram and you are on Medicare, your first question is probably simple: will Medicare pay for this? The short answer is yes, but with conditions. Let us walk through exactly how it works so you are not caught off guard at billing time. Medicare Part B covers echocardiograms when they are deemed medically necessary — a phrase that carries real weight. There needs to be a documented clinical reason, and both the ordering physician and the performing facility must be properly enrolled and credentialed with Medicare before any claim will be reimbursed.

04 Mar

Posted at 11:01h in Medical Insurance, Medicare
[caption id="attachment_72690" align="aligncenter" width="500"]Medicare Eligibility Influences Preventive Care Freepix[/caption] Preventive care plays a central role in maintaining long-term health, particularly among older adults and individuals with disabilities. Services such as annual wellness visits, cancer screenings, cardiovascular assessments, and vaccinations are designed to detect conditions early or prevent them altogether. Yet access to these services often depends on insurance coverage. In the United States, Medicare eligibility marks a significant turning point in how individuals engage with preventive care. Understanding when and how a person becomes eligible for Medicare can shape healthcare decisions, provider relationships, and overall utilization of preventive services.

18 Feb

Posted at 10:25h in Author Interviews, Medical Billing
[caption id="attachment_72453" align="aligncenter" width="500"]Molecular Medical Billing Services Freepix image[/caption] It's harder to pay for health care these days, especially specialized care like molecular testing. It is important for professionals to handle the problems that come up with genetic tests, pathology-based diagnostics, and precision medicine labs. This is the reason why genetic medical accounting is very important. Molecular billing is different from general medical billing because it requires a deep understanding of complex testing methods, payer-specific requirements, changing coding standards, and strict rules for compliance. Working with a specialized billing team is not only helpful for labs and healthcare providers that offer molecular tests, it is also necessary for their businesses to stay in business. This guide describes molecular medical billing services, why they are important, how they work, and how they help diagnostic organizations make more money in the long run.

26 Jan

Posted at 12:12h in Author Interviews, Electronic Records, Medical Billing
[caption id="attachment_72121" align="aligncenter" width="500"]efficient-medical-office-billing.jpg Freepix[/caption] Doctors' offices are not short on responsibility. They manage patient care, compliance, staffing, technology, and the constant churn of insurance rules, all while trying to keep the lights on and the waiting room moving. What often gets less attention is how many of their daily headaches are not clinical at all. They are operational. The good news is that some of the most meaningful improvements happening in medical practices right now are practical, measurable, and rooted in better systems rather than bigger budgets. When Administrative Friction Becomes a Care Issue Front office inefficiencies do more than slow down billing. They ripple outward. A denied claim delays revenue, which stresses staffing. Staffing stress shortens visits. Short visits frustrate patients. None of that helps outcomes, and none of it reflects a lack of effort from medical teams. It reflects a system that asks doctors offices to function like data companies without giving them the right tools. Eligibility errors are a perfect example. Verifying provider credentials across multiple states, plans, and licensing bodies is not glamorous work, but mistakes are costly. Automation and smarter data access are changing that reality. Practices that adopt healthcare payment integrity solutions that boost your payment integrity program with real-time provider eligibility data for all licensed providers across every U.S. state and jurisdiction are seeing fewer denials, faster reimbursements, and far less back and forth with payers. That efficiency shows up directly on the balance sheet, and indirectly in calmer days for staff.

26 Nov

Posted at 10:49h in Social Security

social-security-beyond-your-diagnosis

When you can no longer work because of a serious health condition, your focus is naturally on your diagnosis, your symptoms, and your doctor's orders. You assume that proving how sick or injured you are is the only thing that matters for a Social Security Disability claim. But what many applicants discover too late is that the Social Security Administration (SSA) has a set of non-medical rules it checks first. Failing this initial screening means your medical file will never even be opened. The fear of being denied for a technicality you didn't understand is a major source of stress. The disability benefits system is a lifeline for millions; in December 2023, disability benefits were paid to more than 8.7 million disabled beneficiaries. This article will demystify the SSA's non-medical requirements for both Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). Understanding these rules is the critical first step in determining your eligibility and avoiding a preventable denial. Having a complete picture of these non-medical requirements for Social Security Disability benefits is the first step toward building a strong application.

Key Takeaways

  • The SSA always checks non-medical (or "technical") requirements before they look at your medical records.
  • Social Security Disability Insurance (SSDI) is an insurance program based on your work history and the FICA taxes you've paid.
  • Supplemental Security Income (SSI) is a needs-based program based on your current income and financial resources.
  • Failing to meet the distinct non-medical rules for either program results in a technical denial, regardless of how severe your medical condition is.

14 Oct

Posted at 18:24h in Insurance, Medicare
[caption id="attachment_70986" align="aligncenter" width="500"]medical-insurance-cigna Photo by Pixabay[/caption] Navigating Medicare can feel like wandering through a maze, even for the most diligent seniors. Between dozens of plan options, coverage details, and deadlines, it’s easy to feel overwhelmed. That’s where can Cigna Medicare Advantage plans stand out. Beyond standard medical coverage, they offer hidden perks that make your healthcare simpler, more rewarding, and surprisingly affordable. Let’s explore the lesser-known benefits that can help you make the most of your plan.

Complete Preventive Care beyond the Fundamentals

Cigna aims to emphasize preventative treatment. This covers immunizations, regular checkups, and wellness visits. Many of these services are free or almost so. What sets these plans apart is the expanded preventive care. They include vision and hearing assessments. Certain programs even cover expenses for corrective aids. These small actions help ward off more significant medical problems later. Members of Cigna could also have access to individualized health evaluations. These tests help older people find the right wellness programs. They help identify potential health issues before they become major. Better health outcomes and fewer long-term expenses follow from this.

16 Sep

Posted at 09:20h in Author Interviews, Cancer Research, Cost of Health Care
[caption id="attachment_70691" align="aligncenter" width="500"]oncology-cancer-billing-services Pexels image[/caption] Cancer care is going through big changes due to advancement in healthcare research. For many years, the main treatments were surgery, chemotherapy, and radiation. These are still important, but now new options like immunotherapy and targeted therapy are improving results for patients. But with these new treatments also come new challenges.  They have completely changed how cancer clinics handle billing and payments. For oncology providers, keeping up with these changes is important to stay financially secure. This article looks at new cancer treatments, how they affect billing, the challenges clinics face, and how trusted oncology billing services providers help providers handle these issues.

28 Aug

Posted at 12:39h in Cost of Health Care, Legal-Malpractice, Medical Billing
Manage Medical Bills Kent is known as one of Washington's busiest suburban hubs, and like many cities, it experiences accidents that lead to personal injury claims. Injury settlements often take considerable time due to investigations, negotiations, and legal procedures. Meanwhile, medical bills can pile up quickly, creating financial stress for individuals and families. In such cases, working with a Kent personal injury attorney provides legal direction, but we must also manage our medical expenses carefully while waiting for a resolution.

21 Aug

Posted at 11:20h in Cost of Health Care, Insurance
choosing-long-term-care-insurance.png

Key Takeaways

  • Long-term care insurance is increasingly important as more people live longer.
  • Assessing your personal, financial, and family situation can help you choose the right policy.
  • Understanding policy features and exclusions is crucial to avoid surprises later.
  • Comparing providers and working with agencies or licensed professionals may offer added support.
  • New technology and public policies are changing how long-term care is delivered and financed.
  • Reading recent reviews and news can keep you informed about industry trends.

12 Jul

Posted at 17:01h in AI and HealthCare, Electronic Records, Medical Billing
Data fragmentation among EHRs, claims, and device feeds presents enormous issues for healthcare businesses. A comprehensive approach based on healthcare data aggregation and backed by a digital health platform is needed to address this. Providers can improve productivity and outcomes by integrating disparate information using a uniform data model, improved lakehouse architecture, semantic curation, and AI enrichment. records-healthcare-aggregation The healthcare sector lacks insights despite the volume of data. Because data is scattered across EHRs, claims, devices, and patient-reported systems, clinicians often do not have a complete picture of the patient. This fragmentation leads to delays, inefficiencies, and missed opportunities for early action. A truly connected environment requires meaningful healthcare data aggregation that can standardize, curate, and activate data across the care continuum. The cornerstone of this shift is the use of a robust digital health platform that can combine data from several sources into a single, intelligent stream. Data fragmentation causes needless expenses, delays the delivery of treatment, and impairs decision-making. When important information is scattered between payer files, EHRs, siloed systems, and remote monitoring platforms, clinicians are operating blindly. This challenge affects every touchpoint of patient care. Solving this calls for an advanced aggregation architecture that consolidates and refines all clinical, claims, and device data into a single intelligent patient view. The foundation of this transformation is a Healthcare data platform built for real-time intelligence, not just storage.

28 May

Posted at 12:50h in Cost of Health Care, Diabetes, Pharmaceutical Companies
Reasons for the Price Increase of Insulin .jpg The price of insulin keeps on skyrocketing every year. According to the American Diabetes Association, spending on insulin tripled within a decade. By 2022, the cost had hit a staggering $22.3 billion. Between 2017 and 2022, the inflation-adjusted cost of insulin increased by 24%. This is a significant problem since millions of people suffering from Type 1 and Type 2 diabetes can’t go without the drug. Over the years, people have initiated an insulin overpricing lawsuit. In 2023, Eli Lilly settled for $13.5 million and agreed to cap its price at $35 for four years. So why is insulin so expensive in the United States, and what can you do about it?

17 Mar

Posted at 10:53h in Cost of Health Care, Education

Business Side of HealthcareImage Source

Medicine is about saving lives, but it’s also a business. Behind every appointment, insurance claim, and prescription is a system that runs on strategy, budgets, and management. Today’s healthcare isn’t just about doctors and patients. It’s a network of administrators, insurers, and policymakers working to keep hospitals running and treatments accessible. With rising costs, policy shifts, and new technologies reshaping the industry, strong leadership is more important than ever. In this blog, we’ll explore why understanding the business side of medicine matters, how healthcare leaders shape the industry, and what professionals can do to stay ahead.