Facts are facts, and numbers don’t lie; if you’re trying to win an argument, you need to lay hold of some solid proof. But how to get it—that’s the key question and the main point of this article.
Hospitals and clinicians are well aware that there is an increasing difficulty in getting medical services paid—not just by patients but by insurance plans. Delays and denials are the name of the game it seems, and new tactics are being employed in this modern-day clash over claims. How can facilities and practitioners prevail in such a contest? By delivering hard data to the powers that be.
Just the Facts
According to researchers at Fierce Healthcare, “timely access to individual and collective revenue cycle data streams is making the difference for hospital lobbyists petitioning Washington for more favorable healthcare policy.” This is based on feedback from various representatives of the American Hospital Association (AHA) and the Federation for American Hospitals (FAH).
At a recent convocation of revenue cycle management leaders, vendors admitted that, for years, they were unsuccessful in combatting denials from such plans as Medicare Advantage. However, these companies now see hope on the horizon. With new technology, it is possible to do a deep dive into the data and use hard numbers to indicate where the roadblocks to payment exist and to identify which payers are becoming the most recalcitrant in providing appropriate reimbursement.
A recent study by Kodiak RCA, using such analytics, looked at data from over 1,800 hospitals and 200,000 physicians. A review of the hard numbers indicated a jump in initial denial rates from 10.15 percent in 2020 to 11.2 percent in 2022. The study found another 11.99 increase in the first three quarters of 2023. It is clear, therefore, that we have a growing problem when it comes to getting paid. But what can be done to turn around this trend?
Knowledge is Power
The Kodiak report has given new ammunition to groups like the AHA that have been trying to convince Congress and the administration that medical insurance denials are on the rise.
According to AHA Vice President of Policy, Research, Analytics and Strategy Ben Finder:
It didn’t matter which [administration], it was year after year we’d go in and we’d complain about the MA plans denying care and not doing things. It wasn’t until we started to see data from either OIG, the Kodiak data, large survey data, that we could actually start to affect change. There’s actually a shift in Washington.
FAH Senior Vice President of Policy Don May had a similar story for attendees at the RCM gathering in reference to the recent Change cyberattack. He asserted that having access to national data “was instrumental … so that we could take it to the Hill and bring more eyes, tell those stories that folks on the Hill could understand what the impact was, who this was hurting and how large it was.”
RCM leaders and hospital lobbying groups contend that “patients’ increasing inability to pay stems from insurers’ efforts to dodge reimbursements or limit beneficiaries’ coverage rather than hospitals’ service pricing.” The proof, they say, can be found in “hospitals’ uncompensated care ledgers and claims denials,” which also have the benefit of identifying “bad players” within a community or national market.
“Holding those insurers accountable is a key part of what we’re trying to accomplish,” Finder said. Having more data that sheds light on the current denial trends can be critical in helping those in our nation’s capital to see what’s happening and to hopefully respond to it in a constructive way. Again, numbers don’t lie.
For all the positives RCM data brings to the table, lobbyists contend that there are still a few information gaps in these platforms. For example, a reliance on submitted claims doesn’t give insight into events that did not occur due to payer policies, such as a potential discharge to a skilled nursing facility or inpatient rehab facility. In addition, concurrent denials, or those that occur between the case management team and the payer while the patient is still receiving care in a hospital, may not be adequately captured in the analytics.
Clarifying for policy makers the burdens involved in the prior authorization process and requests for concurrent reviews and additional information, as well as sifting through multiple contracts, is also crucial in driving home the point that the process is increasingly working against those who are simply trying to deliver quality care. As Mr. Finder stated, “If we can show that kind of burden and add some quantitative data to that regulatory cost, that would be huge for us.”
Based on the above, it may only be a matter of time before decisionmakers in Washington D.C. are forced to face the facts and enact policies that will lessen the logjam to reimbursement.