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Top MedLearn Publishing News

Health insurers promise to improve coverage reviews that prompt delays and complaints
Health · United States

Health insurers promise to improve coverage reviews that prompt delays and complaints

68% Center coverage: 118 sources
See the Story
Welfare reform has been postponed, but it isn’t going away
Trump Administration · United Kingdom

Welfare reform has been postponed, but it isn’t going away

100% Left coverage: 2 sources
Editorial: Labour’s overhaul of the benefits system failed because it was clearly a raid by the Treasury looking for savings at speed. The government should produce a Beveridge report for the 21st century – or risk a future, right-wing government taking up the challengeSee the Story
CMS looks for AI experts, physicians and other clinicians to streamline prior authorizations
Medicare · United States

CMS looks for AI experts, physicians and other clinicians to streamline prior authorizations

100% Center coverage: 2 sources
New payment model looks to improve patient care by reducing unnecessary treatments.See the Story

Amid Federal Upheaval, the HHS OIG Presses On – RamaOnHealthcare

Over the past few months, a number of my articles have covered a combination of social injustices and oddities from federal agencies. In this article, IUnited States · United StatesSee the Story

Transparency in Coverage Final Rule – MedLearn Publishing

The healthcare industry’s landscape shifted dramatically with the implementation of the Transparency in Coverage (TiC) Final Rule. For compliance professionals navigating this regulatory terrain, understanding both the letter and spirit of these requirements has become essential – not just for avoiding penalties, but also for leveraging transparency as a strategic advantage. The Regulatory Foundation The […]United States · United StatesRead Article

DRG Downgrades by Commercial Payers: Documentation Defense Tactics – MedLearn Publishing

In the current climate of cost containment, commercial payers are increasingly downgrading MS-DRGs after claims are submitted, not disputing the need for inpatient care, but questioning the clinical support for CCs (complications or comorbidities) and MCCs (major complications or comorbidities). These downgrades reduce reimbursement, often occur quietly, without formal denial letters, and can slip past traditional appeal processes unless hospita…United States · United StatesRead Article

Embracing the Adaptive Case Management Model – MedLearn Publishing

For years, the triad model, comprised of nurse case managers, social workers, and utilization review nurses, served as the three-legged stool supporting the model for hospital case management. Designed in the 1990s to meet regulatory and inpatient care demands, it provided a structured, role-defined approach to patient care coordination. However, as healthcare systems face mounting pressures from staffing shortages, complex patient populations, …United States · United StatesRead Article

The Enigma of Sepsis – MedLearn Publishing

Sepsis is one of the most (if not the most) challenging concepts in the International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM), the Health Insurance Portability and Accountability Act (HIPAA)-sanctioned transaction set for reporting diagnoses in the United States.   No one seems to agree on what exactly sepsis is, or its clinical indicators. Clinicians and the World Health Organization’s (WHO’s) ICD-11 label se…Maryland · MarylandRead Article

Laboratory Question for the Week of June 30, 2025

Open the article to view the coverage from MedLearn PublishingRead Article

Unpacking the RUC Time Study: Where Physician Work Valuation Meets Compliance Risk – MedLearn Publishing

Healthcare reimbursement operates on a fascinating paradox: physician services aren’t paid based on market rates or simple invoices, but on calculated values derived from estimated work, practice costs, and liability. This system, the Resource-Based Relative Value Scale (RBRVS), depends critically on one contested input: physician time. The RBRVS Update Committee (RUC), an advisory group organized by the American Medical Association (AMA), sits …United States · United StatesRead Article

Medicare and Medicaid Paying Their Fair Shares – RamaOnHealthcare

According to the American Hospital Association (AHA), Medicare reimbursed hospitals at just 82 percent of the cost of care in 2022, meaning hospitalsMedicare · United StatesSee the Story

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