Although the payer asserted that the proposed policy was “designed to clarify the appropriateness of anesthesia consistent with well-established clinical guidelines,”2 the medical community quickly registered its fears for patient safety and noted the risks of undervaluing physician services and clinical judgment.
The policy change was ultimately abandoned as a result of widespread backlash; thus, one bad payer behavior was successfully thwarted. Unfortunately, for every instance of bad payer behavior averted, hundreds more are being attempted and often implemented without recourse.
In an effort to reduce their own costs, payers have created an ever-expanding reimbursement obstacle course, imposing strict rules and procedures that must be followed to the letter before physicians can be approved for payment. Once those are in place, the payers may then re-arrange the obstacles, in the form of demanding more clinical documentation, changing their own policies without notice, or even deliberately obfuscating the revised criteria for payment.
Objectively, these tactics can be unfair, and many would not survive appeal, but they serve an ultimate purpose: effectively delaying or deferring payments (or in some cases, never paying), allowing more money to stay in the pockets of payers for a longer period of time. More than half of all denied claims are ultimately paid to healthcare providers,3 but not without significant effort and expense. Insurance companies are counting on the game of attrition, knowing that many physician groups will take the lower rate or write off the denial to avoid the arduous appeals process. This disproportionately affects smaller physician groups who don’t have the resources to support prolonged appeals or litigation. Unfortunately, this has the consequence of forcing some smaller groups out of business and eroding patient access to care.
The industry has caught on to this trend and is actively working to shift the playing field. Fair reimbursement is appropriate and essential to ensure physician groups remain available to serve the patients seeking care at their hospitals or practices. As clinicians and healthcare revenue cycle experts, we are deeply involved in advocacy efforts and have made it our mission to improve reimbursement for facility-based physician groups. To begin, we stay a step ahead of insurance companies as they try to dodge payment using the following four emerging tactics.
1. Complicating the Provider Enrollment Process
In theory, provider enrollment should be a simple first step on the road to reimbursement. Providers, of course, must be registered in a payer’s system in order to expedite payment of claims.
Instead, provider enrollment has become its own arduous process, filled with the same pitfalls and challenges we encounter in the rest of the billing cycle. With no uniformity across payers or states, each payer sets its own enrollment policies and procedures, and they routinely change those policies with little or no notice. These are just a few examples:
- There are varying degrees of enrollment (and re-enrollment) time frames: annual, biannual or sometimes quarterly, and the payer may have changed the time frame since the provider’s last re-enrollment.
- Supporting documentation required by one payer may be completely different from another payer—and it may be different now from what it was last quarter.
- Submission rules change, with payers opening new portals or changing formats often without broad communication.
- Payers set granular rules, down to what color ink must be used to sign a paper application.
With so many payers at play (over 1100 as of 2021), it is nearly impossible for provider groups to keep up with enrollment requirements. In addition, they don’t get much help from payers in this regard, as payers are often slow to respond to clarification questions. These issues directly impact a provider’s revenue. At best, they delay payment until all the enrollment hurdles are cleared. At worst, a provider deemed ineligible at the time of service is denied payment altogether.
2. Excessive Denials
The dramatic increase in claim denials has been well-documented: In just a few short years, we have gone from a 10% overall initial denial rate in 20204 to 15% in 2024.5
We understand how. Payers continue to change claim processes and procedures, introducing new opportunities to deny payment, at least initially. In addition to delaying payment, denial tactics also dramatically increase both the administrative burden and the costs associated with reimbursement.
Among the many denial tactics our teams increasingly see:
Excessive Records Requests
Payers are asking to see more clinical documentation, and they are also putting tighter rules in place around when and how the documentation must be submitted. Any missteps in the response process will lead to denials and/or non-payment.
Prepayment Audits
This formal version of a records request often requires providers to submit considerable documentation on many cases for a specified period of time. The extra document prep and payer review time can add months to the reimbursement process. As an example, some healthcare insurers will automatically deny every Emergency Department E/M 99285 claim until they review and approve the charts. This can be financially catastrophic for physician groups as greater than 30% of ED E/M claims are 99285.
Billing Denials
Just like provider enrollment, the rules and policies around claim submission are elusive, making it increasingly difficult to submit clean claims. Payers throw spaghetti against the wall, changing documentation requirements, submission procedures, deadlines, and even approved codes to see what will stick—and they don’t necessarily publish those changes broadly.
Inappropriate Down-Coding
Payers commonly review claims and determine unilaterally that providers should be paid for a lower level of service than what was actually provided to the patient. We see this routinely in the Emergency Department, for example, where payers try to pay based on the final diagnosis, denying payment for critical tests that were needed to rule out more serious possible diagnoses. Or, they decide based on paperwork that a case wasn’t as complicated or as serious as the treating physicians deemed it to be.
Down-coding is particularly frustrating, as it often involves a misalignment of medical expertise. The clinicians on the payer side who determine the down-codes are rarely specialists in the cases they are reviewing. This form of down-coding is also in clear violation of the Prudent Layperson Standard, a law that requires payers to cover emergency care based on a person’s symptoms, not the final diagnosis. When payers misuse the rule by looking at the patient’s discharge diagnosis, they unfairly penalize Emergency providers who must treat all patients based on their symptoms, and they create financial risks for both patients and providers.
Unfortunately, timely submission and documentation compliance still may not lead directly to payment. It is not uncommon after satisfying all the requests stemming from the initial denial for payers to deny the claim a second time for a completely different reason.
3. Contract Non-Compliance
We often say that reimbursement begins with the contract, and our teams focus on several data-driven strategies to help negotiate favorable rates.6 Unfortunately, even a well-negotiated contract is not immune to bad payer behavior. We continue to find that agreeing to favorable rates is one thing; paying them is another. As part of the revenue cycle process, providers must now build in a step to double check that their contracted rates are being honored.
Even more concerning, it is becoming increasingly difficult to get payers to the negotiating table at all. The patient protections we will talk about in the next section have inadvertently given payers some incentive to keep providers out of network. This gives payers new leverage to keep rates as low as possible.
4. Abusing Patient Protections
Laws that were designed to protect patients and secure access to care are now being weaponized by payers to avoid payment. Two laws, in particular, have opened an unintended back door that allows payers to shift the payment burden over to providers.
Enacted in 1986, the Emergency Medical Treatment & Labor Act (EMTALA)7 ensures public access to emergency care regardless of a patient’s ability to pay, requiring hospitals to provide stabilizing treatment for all patients who present at their Emergency Departments. After treatment, however, insurers deny or reduce payment by asserting the case wasn’t actually emergent and didn’t justify expensive ED management, or by leveraging low out-of-network rates.
Similarly, the No Surprises Act (NSA),8 which took effect beginning in 2022, protects patients from surprise balance-billing from providers. It was intended to limit patients’ responsibility for out-of-network services to approximately what their in-network payments would have been. In effect, however, it removes the incentive for payers to pay higher in-network rates and leaves providers bearing the brunt of the remaining financial responsibility. While the NSA also established an Independent Dispute Resolution (IDR) process for providers to appeal denials and underpayments, the process is notoriously slow and consumes precious administrative resources to navigate.
With effort, disputes related to EMTALA and NSA are winnable—our teams currently win 86% of the cases we appeal through the IDR. But, again, the real payoff for insurers is the delay itself and the money they keep when providers give up the fight.
How Ventra Can Help
The payer landscape is frustrating, to be sure, but there is some good news. We are seeing firsthand that a proactive, data-driven RCM strategy gives providers a fighting chance to get paid appropriately for the services they deliver to their hospitals and patients.
Leveraging decades of specialty expertise and using vSightTM, our best-in-class data & analytics platform, our multifunctional teams at Ventra Health are countering even the most egregious payer behaviors.
- Our Performance Surveillance Team is focused 24/7 on monitoring more than 200 audit controls, which allows us to spot issues—like a spike in denial rates—and correct them before they impact revenue. This is often the fastest way to discover a payer has changed a policy without notice.
- We audit physician documentation to discover opportunities to improve accuracy. Hands-on documentation education helps physicians stay current with coding changes, ensuring they provide the details upfront that will support reimbursement for appropriate levels of care.
- We track and manage enrollment status in tandem with billing, holding claims until enrollment is confirmed to completely eliminate enrollment-based denials.
- A combination of industry benchmarking data, practice data, and longstanding payer relationships helps us build a solid case for rate increases in contract negotiation. Data can demonstrate a pattern of bad behavior or prove that a payer’s proposed rates are not regionally competitive.
- Our leaders are industry advocates, fighting for reforms on Capitol Hill that will improve reimbursement for all facility-based physicians. Many of us are nationally recognized leaders in organizations including the American College of Emergency Physicians (ACEP), the American Society of Anesthesiologists (ASA), the Radiology Business Management Association (RBMA), and more.
Perhaps most importantly, Ventra has the size and strength to level the playing field and win the game of attrition. With support from our private equity partner, we have made meaningful investments in business intelligence technology and exceptional talent that ensure we can go head-to-head with payers on behalf of our physicians.
Because, in the end, bad payer behavior hurts everyone—providers, hospitals, and patients. If payers aren’t paying their fair share of reimbursement, the shortfall doesn’t disappear. The slack must be accounted for in the form of hospital subsidies to help physicians cover deficits and extra clinical work for physicians. By fighting for appropriate reimbursement for physicians, we are helping to rebalance the system for physicians, healthcare systems, and patients.
About Ventra Health
Ventra Health is a leading business solutions provider for facility-based physicians specializing in Anesthesia, Emergency Medicine, Hospital Medicine, Radiology, and Pathology. We are committed to providing innovation, RCM expertise, and white-glove service while delivering transparent and data-driven solutions that solve the most complex revenue and reimbursement issues, enabling clinicians to focus on providing outstanding care to their patients and communities.
As one of the nation’s most advanced technology-enabled providers of comprehensive RCM services, Ventra offers clients access to industry-leading technology, robust data and analytics, provider education, as well as payer strategy and contracting services. Visit www.VentraHealth.com to learn more.
Resources
1 “Anthem Blue Cross Blue Shield Won’t Pay for the Complete Duration of Anesthesia for Patients’ Surgical Procedures,” American Society of Anesthesiologists, November 14, 2024, accessed January 16, 2025, at https://www.asahq.org/about-asa/newsroom/news-releases/2024/11/anthem-blue-cross-blue-shield-will-not-pay-complete-duration-of-anesthesia-for-surgical-procedures
2 “Anthem Blue Cross Blue Shield halts anesthesia payment policy after backlash,” NBC News, December 5, 2024, accessed January 16, 2025, at https://www.nbcnews.com/health/health-care/anthem-blue-cross-blue-shield-time-limits-anesthesia-surgery-rcna183035
3 “Breaking down claim denial rates by healthcare payer,” TechTarget I xtelligent Rev Cycle Management, January 9, 2025, accessed January 16, 2025, at https://www.techtarget.com/revcyclemanagement/feature/Breaking-down-claim-denial-rates-by-healthcare-payer#:~:text=While%20many%20payers%20have%20claim,ultimately%20paid%20to%20healthcare%20providers.
4 “Payers’ increasing claims denials, delays ‘wreaking havoc’ on provider revenue cycles,” Fierce Healthcare, December 14, 2023, accessed January 16, 2025, at https://www.fiercehealthcare.com/finance/payers-increasing-claims-denials-delays-wreaking-havoc-provider-revenue-cycles
5 “Breaking down claim denial rates by healthcare payer,” TechTarget I xtelligent Rev Cycle Management, January 9, 2025, accessed January 16, 2025, at https://www.techtarget.com/revcyclemanagement/feature/Breaking-down-claim-denial-rates-by-healthcare-payer#:~:text=While%20many%20payers%20have%20claim,ultimately%20paid%20to%20healthcare%20providers.
6 “5 Strategies for Successful Provider-Payer Contract Negotiations,” Ventra Health, October 9, 2024, accessed January 16, 2025, at https://ventrahealth.com/blog/5-strategies-for-provider-payer-contract-negotiations/
7 Emergency Medical Treatment & Labor Act, Centers for Medicare & Medicaid Services, CMS.gov, accessed January 16, 2025, at https://www.cms.gov/medicare/regulations-guidance/legislation/emergency-medical-treatment-labor-act#:~:text=In%201986%2C%20Congress%20enacted%20the,regardless%20of%20ability%20to%20pay.
8 “No Surprises: Understand your rights against surprise medical bills,” Centers for Medicare & Medicaid Services, CMS.gov, accessed January 16, 2025, at https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills
