TRICARE Archives - HIT Leaders and News

AI Won’t Save You from Bad Claim Strategy

Jason Free — Tue, 24 Jun 2025 11:21:06 +0000

Last week, EnableComp Chief Strategy Officer Mike Esworthy laid out a clear and compelling framework for tackling one of the most persistently underestimated problems in healthcare finance: the drag of complex claims. These are the 10 to 15 percent of encounters that exist outside the logic of routine reimbursement. They resist automation, evade standard EHR logic, and disproportionately strain revenue cycle teams already operating with fewer resources and tighter margins.

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Inside Mike Esworthy’s Playbook for Tackling Complex Claims

Jason Free — Tue, 17 Jun 2025 10:42:06 +0000

In today’s healthcare revenue cycle, standard claims are no longer the real challenge. The true margin drain hides in the outliers such as complex claims tied to Veterans Affairs, workers’ compensation, TRICARE, and other non-routine payers that fall outside the 80/20 efficiency rule. These edge cases are consuming disproportionate time, staff, and resources while driving up denials and delaying reimbursement. As payer rules grow more fragmented and labor shortages persist, health systems are under pressure to do more with less, and do it with precision.

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The Margin Killers You’re Not Measuring

Jason Free — Tue, 10 Jun 2025 11:07:27 +0000

Hospitals have digitized. They have automated. They have consolidated. But despite more than a decade of transformation in revenue cycle operations, most health systems are still losing efficiency in one costly corner: the complex claims that do not fit inside commercial or Medicare billing templates. These edge cases such as Veterans Affairs encounters, workers’ compensation claims, TRICARE submissions, and motor vehicle accidents, consume disproportionate resources and often delay payment for months.

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Former Georgia Insurance Commissioner John Oxendine Pleads Guilty in Healthcare Fraud Scheme

Jason Free — Thu, 28 Mar 2024 12:37:44 +0000

John W. Oxendine, the former Georgia State Insurance Commissioner, pleaded guilty to conspiracy to commit health care fraud in which a co-conspirator and he referred unnecessary medical tests to a lab company in Texas in return for hundreds of thousands of dollars in kickbacks.

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Three Men Sentenced for $54M Fraudulent Prescriptions Scheme

Jason Free — Thu, 30 Nov 2023 14:40:02 +0000

Three men were sentenced in connection to a $54 million bribery and kickback scheme involving TRICARE, a federal program that provides health insurance benefits to active duty and retired service members and their families.

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