Private Payers Retain Profits by Denying, Delaying Claims: What Rev Cycle Leaders Can Do About It

While health systems are doing their best to maintain financial stability, payers are doing their best to protect their profitability.

A new report from Premier Inc found a trend in private payers denying claims, including prior authorizations. Out of all claims submitted to private payers for reimbursement, 15% were initially denied when submitted. Most of these claims were for higher-cost treatments.

Over half of the claims denied by private payers were approved and paid, but only after multiple rounds of appeals, according to the report. The average cost for providers fighting a denial was $43.84.

What Can Providers Do?

Payer struggles are a consistent issue for revenue cycle operations, being time consuming and costly, but revenue cycle leaders can push back.

Systems like Grady Health and its billing subsidiary, One Grady, have found success in building additional automated solutions onto its existing interface.

The solutions are leveraged alongside the efforts of revenue cycle staff and Monica Richey, vice president of physician revenue, previously told HealthLeaders that identifying issues within denials and maintaining communication with payers has helped the team stay on top of any issues.

“We’re having to be very intentional and strategic about the way in which we handle denials and really dig into how we operationalize our workforce to be able to manage those denials,” Richey said.

Since payers have also been implementing automated and artificially intelligent solutions into their operations, systems like OSF Healthcare, having a substantial presence of technology in their revenue cycle operations, are able to meet payers halfway.

Cathy Beebe, director of ministry managed care, encourages all payers to utilize their EHR’s payer payment platform to streamline the claims process.

“Sometimes I have to threaten that if they don’t get that module turned on, I will turn off the clinical data exchange because we could force them to have to request paper medical records through a vendor,” she previously told HealthLeaders.

“I hate to be mean, but sometimes we have to do that,” Beebe said.