Denial rates have soared to unprecedented levels, transforming what was once a back-office nuisance into a boardroom-level issue for health systems. At Becker’s 13th Annual CEO + CFO Roundtable, two leaders from Conifer Health Solutions laid out a framework for defending revenue in today’s challenging reimbursement environment.
In the session titled From denials to dollars: Leveraging tech and operational excellence to protect revenue, Kyle McElroy, vice president of clinical operations, and Rhonda Kamenick, senior director of clinical revenue cycle operations, shared how their organization is adapting to payers’ AI-powered denials and the surge in administrative complexity.
Here are four key takeaways from the session:
Note: Quotes have been edited for length and clarity.
1. Denial rates are rising at an exponential — not incremental — pace
Health systems are no longer seeing denials tick upward year over year — they’re watching them spike month over month. “It’s not that we’re doing worse on the back end,” Ms. Kamenick said. “The payers are just denying significantly more because they have a lot of tools at their disposal.”
Much of that spike, according to Ms. Kamenick, is driven by payers’ use of artificial intelligence to automate denials, often based on narrowly interpreted coverage criteria. As a result, nearly one in four claims now receives an initial dispute, Mr. McElroy said.
2. Back-to-basics thinking still matters
Conifer’s leaders encouraged health systems to double down on denial prevention across the revenue cycle, with a special focus on the mid-cycle. This is an area where Mr. McElroy said “a lot of leakage” often occurs.
The team shared a range of process fixes — from reducing plan code errors to better managing payer portals — that can lead to measurable reductions in denials. For example, incorrect CPT code alignment with prior authorizations was cited as a common cause of avoidable denials.
3. Clinical appeal teams need specialized support and smarter tools
Clinical denials require clinical expertise and the right tools to match. Ms. Kamenick, a nurse by background, described how her team uses advanced software to help nurses draft appeal letters more efficiently, without replacing their clinical judgment. These tools reduce the time spent reviewing voluminous records and improve consistency across letters, but clinicians still make the final call.
4. Governance and payer collaboration are essential to long-term gains
Technology and analytics can streamline appeal workflows, but sustaining gains requires strong internal governance and external partnerships. Conifer recommends establishing dedicated feedback loops, standardized KPIs and quality audits — especially for high-dollar denials.
Equally important is reengaging with payers. Joint operating committee meetings are regaining traction as a venue to escalate unresolved disputes and push back on recurring denial patterns, such as automatic downgrades of inpatient stays or NICU services.
