This was the focus of an executive session at Becker’s 12th Annual CEO + CFO Roundtable, where Mike Morris, CEO of Xtend Healthcare, a CorroHealth company, and Geoff New, EdD, senior Vice President of clinical documentation and denials management at CorroHealth, discussed the payer denials problem and how data and analytics can serve as a solution.
Three key takeaways were:
1. Increasing payer denial rates is a major concern for hospitals and health systems.
According to Mr. Morris, more than half of American Hospital Association members surveyed last year reported their MA denials rate was between 21% and 30%. “In addition, an enormous 82% of respondents said they had three or more payer escalations within the year, with a whopping 95% believing that trend is going to continue,” he said.
2. The factors behind the growing denials problem are varied and complex.
Session participants from both payer and provider organizations shared their perspectives: One participant said payers often believe “if the provider could just file the claim correctly, the payer would pay right away.”
Another participant countered that more payer edits are being introduced into the process. “We see claims that are paying clean today suddenly get stuck tomorrow, and it’s because a new edit got introduced and was poorly communicated to the providers,” the participant said.
Another participant said they believe “a greed element” has been infused in the process, and that “COVID allowed the payers to recognize profits that they just don’t want to let go of now.”
3. Data from CDI systems can better equip providers to contest denials.
By using CDI data and analytics, providers are better informed and prepared to respond to and challenge payers.
Mr. Morris and Mr. New described how VISION clinical validation technology from CorroHealth can instantly select, score and prioritize clinical cases to improve DRG integrity, giving healthcare organizations a four- to 10-fold revenue lift. VISION helps organizations compliantly maximize reimbursement by safeguarding against payer denials.
