Payer Operations Management

Turning Denial Data Into Action: How Healthcare Organizations Can Fight Back Against Payer Denials

Healthcare providers across the U.S. are facing a growing wave of claim denials that is putting pressure on already strained hospital finances. Industry research from the American Hospital Association shows that nearly 15% of medical claims submitted to private payers are initially denied, forcing hospitals and health systems to spend about $19.7 billion annually attempting…

SHMS Optimizes Operations for Medicare Advantage Plan Operators in the Healthcare Payer Enterprise

Enrollment in Medicare Advantage plans is projected to reach about 35.7 million, according to a 2025 Senate Finance Committee report. Yet, many startup and midsize organizations face steep technical and regulatory hurdles when launching or scaling operations. As part of the broader healthcare payer enterprise landscape, these plans must manage compliance, claims adjudication, risk adjustment,…