Denials prevention and resolution — 4 roundtable takeaways

During an executive roundtable at the 8th Annual Becker's Health IT + Digital Health + RCM Meeting, two leaders from Aspirion — Jeff Podraza, president and general manager denials resolution and prevention, and Nancy Momcilovic general manager workers' compensation and medicaid services —  discussed denial prevention. 

The conversation touched on the importance of managed care contracts and agreements, and how they relate to state and federal law and payer policy. The speakers highlight the need for health systems to have a clear understanding of their managed care landscape and to optimize their agreements. They also discussed the importance of having a clear and effective dispute resolution mechanism in place. They noted that denials have increased since 2020. They also discussed the importance of having clear and realistic exceptions in contracts, and the need for collaboration between different departments within a hospital when negotiating contracts.

Editor's note: Quotes have been edited for length and clarity.

4 takeaways + quotes:

1. Collaborate with all departments in the hospital during the negotiation of managed care agreements to ensure all costs are covered. 

Nancy Momcilovic: When the contract is being negotiated, it really should be a collaborative effort across departments to make sure everything is covered at the necessary level to make sure costs are being covered.

2. Incorporate realistic exceptions and conditions into managed care agreements to prevent denials. 

NM: I've reviewed hundreds of managed care agreements, there's very little balance in these agreements. They're lopsided, there's a benefit to the payer but no benefit back to the provider. So what do you do? And this is where you step back and go 'you know what, it's time to renegotiate and balance our agreements.'

3. Stipulate the clinical review criteria in managed care agreements to ensure consistency in determining medical necessity.

Jeff Podraza: Very few agreements will stipulate the clinical review criteria that both parties should be using, but this is beginning to change and can help prevent denials.

4. Advocate for provider appeal rights and the use of Independent Review Organizations (IROs) in managed care agreements. 

NM:  With an IRO, the carriers know that there's somebody looking over them on these denials. And so we see less and less denials happening at that second level of appeals.

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