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USA Today
3 days ago
- Health
- USA Today
A $101,000 knee replacement? Why some hospitals charge far more than others.
People are usually savvy enough to check whether their hospital or doctor takes their insurance. But it's often a mystery how much a medical procedure or operation will cost, even with coverage. A new report from Trilliant Health, a health care analytics company, shows how much prices for the same medical service can vary at different hospitals and surgery centers. Want a total knee replacement? It can cost as little as $12,870 or as much $101,527. An ankle replacement? An Austin, Texas, hospital charges $22,011 while a New Jersey hospital billed more than $197,000 for the same operation. These wide price swings can leave insured consumers with big bills, loans and medical debt. Using claims data from two major health insurers, Trilliant Health analyzed inpatient and outpatient rates charged by nearly 2,700 hospitals and 3,500 surgery centers. The report found prices can vary as much as nine-fold for the same operation or procedure. And hospital prices within the same state varied more than three-fold, the report said. Trilliant also analyzed 10 hospitals listed on multiple best hospital lists and found no link between higher prices and improved health quality. Allison Oakes, chief research officer for Trilliant Health, said the report aims to inform consumers and employers on health care prices so they can better gauge the value of services they are purchasing. Oakes said health care prices − and the discounted rates negotiated by insurance companies − historically have been a "very well protected industry secret." "The fact that we now have information related to price, we can hopefully begin to rein in our spending," said Oakes. Hospital prices drive health spending higher Research shows said such price variation is a key contributor to why health care costs so much more in the United States than any other nation. The U.S. spent $4.9 trillion in health care in 2023 − or $14,570 for every person. Despite spending more than any other nation, U.S. life expectancy is the lowest among large, wealthy nations, according to the Peterson-KFF Health System Tracker. Employers who pay for health insurance for working-age adults historically didn't have prices when deciding which hospitals and surgery centers to include in their workplace insurance plans' networks. Consumers with high-deductible health plans often pay thousands of dollars out of pocket before coverage kicks in. Or they often are charged coinsurance, which requires they pay a percentage of a medical bill. Over the past 25 years, the cost of employer health insurance premiums has nearly tripled the rate of workers pay raises, according to a 2024 study in peer reviewed Health Affairs. A major contributing factor: hospital prices. Under federal price transparency rules adopted earlier this decade, health insurance companies must disclose prices negotiated with hospitals and other health providers. Trilliant's analysis included prices negotiated by two national health insurers: UnitedHealth Group and Aetna. Will price transparency spur competition, lower prices? Researchers not involved in the Trilliant report have analyzed price transparency data and reached similar conclusions about widespread price differences. One study by Johns Hopkins University found prices of X-rays and CT scans varied more than 10-fold nationwide. The study found prices for the same scan in the same hospital nearly tripled based on different plans from the same insurance company, said Ge Bai, a Johns Hopkins University professor of accounting and health policy and management. Bai said the study underscores the lack of competition in health services. "We have a long way to go before we can reach a competitive market for health care prices," Bai said. Rice University's Baker Institute compared prices of three Houston hospitals and found large price differences negotiated by three health insurers: Blue Cross Blue Shield of Texas, United Health and Humana. The biggest price gap: an overnight stay covered by a Humana PPO plan ranged from an average of $17,628 to $57,898 at different Houston-area hospitals. Vivian Ho, a Rice University economist who has studied hospital pricing, said employers can use pricing information to tailor their health insurance offerings to workers. "There is a great deal of opportunity for employers to take this information and start restructuring their benefits," Ho said. A large New York labor union attempted to steer employees away from New York-Presbyterian to other hospitals as part of a cost-savings move. The union, Local 32BJ of the Service Employees International Union, requested the Justice Department investigate New York Presbyterian over claims that anti-competitive behavior kept hospital prices high. The Justice Department has launched an investigation into the high-profile hospital chain and its insurer contracting practices, according to a subpoena reviewed by the New York Times. A New York-Presbyterian spokesperson declined to comment. Another study of Massachusetts health plans that examined the use of tiered pricing that charged consumers higher copays if they chose more expensive hospitals. Consumers could choose copays of $250, $500 or $750, with the higher copays linked to more expensive hospitals. After three years, overall spending dropped by more than 8%, an indication consumers were willing to choose lower-cost copays and hospitals. Ho said the tiered copay approach is easier for consumers to understand health prices − and what steps they can take to lower their costs. "The average consumer doesn't understand the problem," Ho said. Consumers are quick to blame their insurer when health prices rise, Ho said. And while insurers have been scrutinized for practices such as prior authorization and service denials, the main driver of health insurance premiums are hospital charges for both inpatient and outpatient services, Ho said. "The hospitals and the consolidated health care systems are charging very high prices," Ho said. "And there's nothing in your health insurance benefit to stop you from going to the highest-priced providers." Email consumer health reporter Ken Alltucker at alltuck@
Time Business News
12-08-2025
- Health
- Time Business News
How to Reduce Medical Claim Denials
The healthcare industry in the United States is facing a severe crisis. A silent parasite that is putting a strain on both healthcare providers and patients. Both small practices and large hospitals are suffering from it and losing billions of dollars every year. You might be wondering what it is? Well, Insurance Claim Denials. Denials have reached alarming levels, creating administrative burdens that consume valuable resources and delay essential treatments. Recent industry data reveals that providers are spending over $25.7 billion annually just to fight claim denials. However, preventing and resolving the denials is relatively easy if done correctly. In this guide, we will discuss exactly how you can tackle the denials and improve your practice's revenue. So, let's start. Current Stats Behind Claim Denials Like we said above, the healthcare industry is experiencing tons of denials that are not easy to deal with. To give you an idea, let's look at some data. According to Experian Health's report published in 2024, 38% of healthcare providers, including both small practices and large hospitals, report that at least one in ten claims is denied. While some of them are experiencing denial rates exceeding 15%. These are not just denials on paper. It is actual money that you are losing! Imagine 15% revenue just lost because of small mistakes. And guess what? The denials are increasing every year. Recently, 77% of providers reported that denials are increasing compared to just 42% in 2022. Medicare Advantage plans present particular challenges, with research from Health Affairs showing an initial claim denial rate of 17%, though 57% of these denials are ultimately reversed. The financial impact is substantial – providers lose approximately 7% of total dollars initially billed due to claim denials that remain unresolved. Primary Causes of Medical Claim Denials There can be many causes for denials. Human coding error, filing the claims after the deadline, using the wrong modifiers, or just a simple mistake like writing the wrong spellings. So, what can you do about it? Well, before you can resolve the denials, it's necessary to understand the causes of denials. Understanding why claims are denied is the first step toward prevention. Even though there are tens of reasons for denials, all of them can be categorized into the following two categories: Data Quality Issues Missing or inaccurate patient information Incomplete documentation Incorrect coding or billing errors Authorization Issues Missing prior authorization Expired authorizations Services deemed not medically necessary Failing to get prior authorization is one of the biggest challenges. Physicians spend an average of 13 hours per week completing prior authorizations, with 93% reporting that this process delays necessary care. All of this work and hassle can be avoided by implementing the strategies that we are going to discuss in the next section. Proven Strategies to Reduce Claim Denials Eligibility Verification One of the most effective strategies is verifying patient eligibility and benefits before every appointment. This prevents denials due to coverage lapses, plan changes, or incorrect patient information. Automated eligibility verification tools can streamline this process and catch issues before services are rendered. Prior Authorization Workflows We already know that pre-authorization is a headache. To counter it, you can create workflows and checklists. Wondering what to include in your workflows? Here's what we suggest: Creating standardized checklists for different types of services Training staff on payer-specific requirements Implementing automated prior authorization software Establishing clear timelines for submission and follow-up Claims Scrubbing Technology You might not know this yet, but claim scrubbing is an actual thing. And you don't have to do that yourself. There are automated software programs in the market that can do it for you. Automated claims scrubbing tools can identify and correct errors before submission. These systems check for common issues such as missing information, coding errors, and payer-specific requirements. So, even if your billing teams make any errors while filing the claims, the software can detect it and correct them before submitting them to the insurance company. Get RCM Services The simplest and also the most money-friendly way of reducing the claims is to just outsource your billing operations to specialized RCM service providers. Why? These companies have decades of experience in filing claims and managing denials. They charge a minimal amount and deliver amazing results. However, you need to ensure one essential thing before outsourcing. Not all billing companies are good, and generalized billing companies can't help you if you have a specific specialty practice. So, select a billing partner that has expertise in your specific domain. For example. If your healthcare practice deals in gastroenterology, get help from gastroenterology billing service providers, not ENT billers. Wrapping Up That's it! We have tried our best to provide all the information you need to avoid claim denials and prevent them from ever happening. Unfortunately, even with all the precautionary measures, denials will happen. They are simply inevitable. But what you can do is outsource the entire billing operations to specialized billing companies, so you don't have to go through the hassle. TIME BUSINESS NEWS
Yahoo
14-07-2025
- Health
- Yahoo
Medically Tailored Meal Companies Want to Send You Fresh Food for Free. (If You Qualify.)
"Hearst Magazines and Yahoo may earn commission or revenue on some items through these links." WHETHER YOUR pressure is on the upswing or your stomach's always wrecked, one of the first things your doctor might ask is, 'What's your diet like?' They'll probably tell you to cut back on greasy takeout and eat more vegetables, then come back in a month for a quick check-in. This guidance is so vague, it almost feels pointless. Cut back … forever? Eat more … how? The 'food is medicine" movement wants to eliminate that confusion: Proponents believe doctors should be better educated about nutrition, and sick patients should receive an Rx for groceries and healthy meals. The idea is, by making high-quality food easier to access, our healthcare system will be better equipped to prevent—and even treat—disease. Prescribing medically tailored meals (MTMs) is one way to go about this: Dietitians personalize prepared meals to meet the needs of people with chronic health conditions. The goal is to improve their health and quality of life while also cutting down on medical bills. Research suggests this concept could do a lot of good. A 2025 study published in the journal Health Affairs estimates that a national MTM program would save the U.S. a whopping $32 billion in healthcare costs. So far, the benefits—fewer symptoms, less frequent hospital visits, better odds of living longer—are most promising for people with HIV/AIDs, diabetes, heart failure, cancer, and kidney disease, but scientists have only scratched the surface, says Seth Berkowitz, MD, MPH, the section chief for research at UNC School of Medicine. (Dr. Berkowitz investigates the health outcomes of medically tailored meal interventions.) While you may have only recently heard of medically tailored meals, the Food Is Medicine Coalition (FIMC) has been fine-tuning them for decades, says executive director Alissa Wassung. Its nonprofit agencies partner with chefs and dietitians across 25 states to deliver medically tailored meals, medical nutrition therapy, and nutrition counseling to people living with cancer, diabetes, heart disease, the list goes on. The people the agencies serve receive meals for free, thanks to state and federal programs and philanthropic donations. It seems like a no-brainer: If you give people healthy meals, surely they'll get healthier. But the current state of MTMs is not without growing pains. Recently the space has become crowded and confusing. Dozens of ambitious start-ups have boarded the food-is-medicine train. They, too, deliver prepared meals marketed as dietitian-approved and medically tailored, sometimes for no or low cost with health insurance. In theory, having more MTM providers would be a great thing. It'd mean that more people could use a much-needed service that's sparse or nonexistent in many parts of the country. But grassroots advocates worry that some for-profit companies are using misleading marketing tactics and skimping on quality. 'When they start using the term 'medically tailored' without specific standards and definitions, it really does dilute the entire movement,' says Jean Terranova, senior director of policy and research at Community Servings, a FIMC-accredited agency that delivers MTMs in Massachusetts and Rhode Island. Plus, the scientific community still needs more research to understand when these meals make a true difference in people's health. (There's not yet a federally recognized nutrition standard for 'medically tailored.') And certain meal providers have already been called out for delivering pricey, processed junk. DR. BERKOWITZ SUSPECTS that many start-ups are responding to the genuine need for more meal providers across all states. But the most solid data on MTMs is based on grassroots organizations that have built their practices over many years with feedback from their local communities. FIMC agencies pioneered the blueprint for MTMs nearly 40 years ago as a response to the HIV/AIDS crisis. Replicating their wins is a tall order in a fast-paced, tech-driven landscape. Case in point: A report from STAT News, which found that Homestyle Direct—an Idaho-based company that recently rebranded itself as an MTM service—actually shipped subscribers not-so-healthy frozen meals. One 'diabetes-friendly' option included a Jimmy Dean sausage breakfast sandwich that packed nearly 1,000 milligrams of sodium. Yet the company has the potential to make millions, in part by billing taxpayer-funded Medicaid programs. 'That's exactly what you don't want to see,' Terranova says. The STAT News report also scrutinized other meal-delivery companies that bill Medicaid, including Mom's Meals, for its pureed cheeseburgers (yum?) and oatmeal cream pie, and Magic Kitchen, for its biscuits and gravy. FIMC published its first public-facing MTM requirements in 2024. The 32-page document is their 'commitment to excellence,' Wassung says. It outlines best practices for integrating full-time dietitians, assessing clients' needs, and meal preparation. Accredited agencies, a designation that's currently only offered to nonprofits, should meet the following criteria. They should not serve or deliver 'ultra-processed' foods or dishes that contain artificial sweeteners, high fructose corn syrup, or preservatives. They should prioritize using 'as many fresh ingredients as possible' and offer them ways of baking, braising, and sauteing rather than frying. The food should arrive fresh and lend itself to freezing or reheating. It needs to taste good, too. (Yes, they actually conduct taste tests.) 'We've invested significantly in research,' Terranova says. So if newer companies aren't striving for the standards that led to the impressive results in that research, 'we're afraid that could reverse the trajectory of the policy wins,' she explains. That concern has only grown as the federal government zeroes in on 'efficient' spending. 'We're seeing potential cuts to Medicaid,' Terranova says. 'We want to make sure we're not straying from interventions that work.' So, it's a tricky situation. Profit-driven companies can make, market, and price their meals however they'd like. For those that have the option to bill Medicaid, what constitutes a 'medically tailored meal' varies by state, some of which have shockingly loose requirements. And it raises worthwhile questions about oversight. 'True, fair competition can be a good thing in many cases,' says behavioral scientist Justin B. Moore, PhD, a professor of public health sciences at Wake Forest University School of Medicine who has researched MTMs. 'But I do think [the competition is] muddying the water.' NO START-UP HAS perfected MTMs, but some have shown a decent effort. Take Epicured, a New York-based company that specializes in low-FODMAP meals, which are sometimes better tolerated by people with digestive conditions like irritable bowel syndrome (IBS) and Crohn's. The plan involves nixing dairy, wheat, legumes, and certain fruits and vegetables, so it can be tough to follow. Epicured announced a partnership with Mount Sinai in 2019, propped by a large financial investment from the health system. Laura Manning, MPH, RD, clinical nutrition manager at Mount Sinai Hospital, is one of the dietitians who works with Epicured to develop the criteria for its 'therapeutic' menu items, which include pad Thai, chicken bacon lasagna, and lamb ragu pasta. She says patients who have benefited the most are actually in their 20s and 30s—they're working crazy hours and 'too busy to figure out how to cook all this stuff.' When a patient with GI issues is referred to Manning for a low-FODMAP diet, she'll sit down with them for an hour to learn about their current diet and lifestyle. She'll ask questions like, 'How do you prepare your meals? What does that look like in a day? Do you enjoy cooking?' She wants to give them helpful information about how their diet could mess with their gut, but also an actual plan—when it makes sense, she'll recommend starting with Epicured. You don't need to sit down with a dietitian to buy Epicured's meals, though the company and the experts we spoke with highly encourage that step. You can just go to its website, select what looks good, and hit 'checkout'—final price pending on insurance. The company says the meals arrive freshly prepared, chilled, and ready to eat or heat. (Worth noting: Epicured only offers the elimination phase of a low-FODMAP program. It's in the final stages of creating meals for the reintroduction and personalization phases—not something you can truly pull off without the guidance of a clinician.) Others operate similarly: Performance Kitchen and ModifyHealth, for example, partner with various health insurance providers that may include dietitian support, but also allow you to peruse their menus and purchase meals yourself. You'll find diabetes-focused, heart-healthy, kidney-friendly, GLP-1-support, and low-FODMAP options—plus a bunch geared toward overall wellness, like vegetarian and Mediterranean dishes. UNFORTUNATELY, ALL THESE complexities means that the burden falls on you to figure out what's legit, says Abby Langer, RD, a Men's Health nutrition advisor and the owner of Abby Langer Nutrition. She thinks it's a little shady that so many of these companies don't directly name who they partner with to make their meals—or spell out the nutrition requirements they abide by. Which brings us back to the question of quality. Some companies seem to stack up on the nutrition front, while others serve up calorically dense options not unlike the ultra-processed foods that the 'Make America Healthy Again' movement is cracking down on. Some ship frozen meals while others deliver them fresh. Some require a meeting with a dietitian or a referral from a clinician, while others let you 'add to cart' instantly. Some give off mystery meat vibes while others look impressively gourmet. Most of them are expensive, hovering around $10 to $20 a plate, not including shipping costs. (It goes even higher. At Epicured, sea bass, broccoli, and potatoes will run you $32 with delivery fees.) 'If you've got the means or insurance, awesome. But most people don't have the means or the insurance, which implies that health disparities will increase,' Moore says. 'If only people with money can get these things and people without money cannot, the gap between them will increase. From an ethical standpoint, it's terrible.' And then there are questions about end game. 'Consider the long-term viability of these programs,' Langer says. 'Are you going to order meals forever? Are you learning what kind of meals are appropriate so you can eventually make them yourself?' Moore agrees: 'It doesn't get at behavior change, at motivations.' However, Manning thinks of the service as a stepping stone for her patients. 'If they see it in front of them, prepared in a way they haven't thought of before, it can inspire them to continue to eat this way,' she says. They probably won't lean on Epicured meals forever—once they get through the elimination phase of the low-FODMAP plan, she helps them slowly reintroduce specific foods to pinpoint their GI triggers. Eventually, instead of ordering three meals a day, for example, they may order a few per week, or whatever fits their lifestyle. Ultimately, it's too soon to tell how this all shakes out. 'I don't think it will be the case that no start-ups can do this. Of course, I think some can learn,' Dr. Berkowitz says. 'On the other hand, there could be some learning curves over the next five to 10 years as more try to get involved, scale it, and bring these interventions to more people.' We'll leave you with this: If you have insurance (or the financial means) and want to try a medically tailored meal service, it may be worth a shot—but only if it's transparent about who's designing and cooking the meals, the nutrition specs of each dish, and how it upholds quality. Otherwise, you risk opening up your diet to something you shouldn't have to consume anymore of: B.S. You Might Also Like The Best Hair Growth Shampoos for Men to Buy Now 25 Vegetables That Are Surprising Sources of Protein
Yahoo
13-06-2025
- Health
- Yahoo
Opinion - Medically tailored nutrition can help make America healthy
Chronic disease is a threat not only to Americans' physical health but also to the nation's financial health. Conditions like heart disease, cancer, diabetes and kidney failure account for trillions of dollars in annual health care spending and are among the leading causes of death in the U.S. The growing consensus is clear that our health care system needs better solutions to manage chronic diseases. One promising tool is surprisingly simple: food. But not just any food. We need nutritious, locally sourced, medically tailored meals — food-based interventions designed by registered dietitian nutritionists specifically for chronically ill Americans. These medically tailored meals are proven to improve health outcomes, reduce hospitalizations and lower health care costs. Just as important, they can reduce patients' dependency on medications, making health care more effective and affordable. At the Boston-based nonprofit I lead, we have seen firsthand how medically tailored meals can transform lives. One of our clients, for example, reduced his daily medications from 14 to just four after enrolling in our program. This is what we mean when we say 'food is medicine' — food, either alone or in conjunction with pharmaceuticals, can help patients become and stay healthier. These meals are not only about nourishment. They are about addressing the root causes of chronic diseases while offering real cost savings. Medically tailored meals prioritize nutrition, treating the underlying causes of disease, not just symptoms. They reduce dependence on medication, leading to fewer prescriptions and better health outcomes. These meals prioritize fresh ingredients over processed foods, with a commitment to quality local food. They lead to immediate cost savings, with reductions in hospitalizations and medical costs. And they support local businesses, strengthening local farms and fishing industries through prioritization of regional sourcing. Does it work? The evidence is clear. Studies published in JAMA and Health Affairs show that medically tailored meals reduce hospitalizations by 49 percent and emergency room visits by 70 percent. They have also been shown to lower total medical costs by a remarkable 16 percent. Another recent study published in Health Affairs estimates that a nationwide rollout of medically tailored meals could save $32 billion annually. In a time of policy uncertainty, one thing is clear: 'Food is medicine' is a bipartisan opportunity to transform health care. The Make America Healthy Again movement is dedicated to reducing the burden of chronic diseases, decreasing reliance on pharmaceuticals and integrating nutrition into health care. The Senate MAHA Caucus is already focused on improving access to high-quality, nutrient-dense foods and addressing the root causes of disease. Congress should act now to expand medically tailored nutrition for veterans, older Americans and people with disabilities — groups who stand to benefit the most. Let us seize this moment and make medically tailored nutrition a central part of making America healthy again. David B. Waters is the CEO of Community Servings, a Boston-based nonprofit provider of medically tailored meals and nutrition services, and founder of the AMPL Institute. Copyright 2025 Nexstar Media, Inc. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.
The Hill
13-06-2025
- Health
- The Hill
Medically tailored nutrition can help make America healthy
Chronic disease is a threat not only to Americans' physical health but also to the nation's financial health. Conditions like heart disease, cancer, diabetes and kidney failure account for trillions of dollars in annual health care spending and are among the leading causes of death in the U.S. The growing consensus is clear that our health care system needs better solutions to manage chronic diseases. One promising tool is surprisingly simple: food. But not just any food. We need nutritious, locally sourced, medically tailored meals — food-based interventions designed by registered dietitian nutritionists specifically for chronically ill Americans. These medically tailored meals are proven to improve health outcomes, reduce hospitalizations and lower health care costs. Just as important, they can reduce patients' dependency on medications, making health care more effective and affordable. At the Boston-based nonprofit I lead, we have seen firsthand how medically tailored meals can transform lives. One of our clients, for example, reduced his daily medications from 14 to just four after enrolling in our program. This is what we mean when we say 'food is medicine' — food, either alone or in conjunction with pharmaceuticals, can help patients become and stay healthier. These meals are not only about nourishment. They are about addressing the root causes of chronic diseases while offering real cost savings. Medically tailored meals prioritize nutrition, treating the underlying causes of disease, not just symptoms. They reduce dependence on medication, leading to fewer prescriptions and better health outcomes. These meals prioritize fresh ingredients over processed foods, with a commitment to quality local food. They lead to immediate cost savings, with reductions in hospitalizations and medical costs. And they support local businesses, strengthening local farms and fishing industries through prioritization of regional sourcing. Does it work? The evidence is clear. Studies published in JAMA and Health Affairs show that medically tailored meals reduce hospitalizations by 49 percent and emergency room visits by 70 percent. They have also been shown to lower total medical costs by a remarkable 16 percent. Another recent study published in Health Affairs estimates that a nationwide rollout of medically tailored meals could save $32 billion annually. In a time of policy uncertainty, one thing is clear: 'Food is medicine' is a bipartisan opportunity to transform health care. The Make America Healthy Again movement is dedicated to reducing the burden of chronic diseases, decreasing reliance on pharmaceuticals and integrating nutrition into health care. The Senate MAHA Caucus is already focused on improving access to high-quality, nutrient-dense foods and addressing the root causes of disease. Congress should act now to expand medically tailored nutrition for veterans, older Americans and people with disabilities — groups who stand to benefit the most. Let us seize this moment and make medically tailored nutrition a central part of making America healthy again. David B. Waters is the CEO of Community Servings, a Boston-based nonprofit provider of medically tailored meals and nutrition services, and founder of the AMPL Institute.
