Trends in Payor Denials in the Healthcare Industry

April 25, 2023
Cara Schildmeyer

 

In the healthcare sector, it is becoming increasingly challenging for patients to receive insurance coverage for their services; payor denials are increasing. Oftentimes, insurance companies are deciding that certain services are not “medically necessary,” making it more difficult for patients to receive access to the care they need. In fact, in 2021, almost 17 percent of in-network healthcare claims were denied—that’s almost one in every five! And combatting an insurance denial is an extreme headache, so healthcare workers and patients don’t always fight back for coverage.

Why is there such a high number of payor denials and how can healthcare companies and patients combat this?

On today’s episode of the RCMchat podcast by AGS Health, host Michelle Dawn Mooney speaks with Matthew Bridge, SVP, RCM Service Line and Erica Franko, SVP of Customer Success, both of AGS Health, to discuss payor denial management in healthcare.

Mooney, Bridge, and Franko also discussed…

  1. The recent trend in the uptick of insurance denials
  2. Reasons why denials are up in healthcare
  3. Suggestions for management within organizations struggling with the increase in denials

Franko discussed how and why authorization rules contribute to denials. “Things like authorizations, I think a couple of factors go into that. One, the rules are changing all of the time. There are several organizations today who have technology on that side. When we dig a little bit deeper into what that technology is, it often has a group of people in the background who are scouring payor websites, who are scouring government websites to actually figure out what are the rules around authorizations? Because, like I mentioned earlier, they can often change on the dime. And so, those are being fed into technology systems that hopefully are helping people who are sitting in an office actually process those denials.”

“It really requires a line in between your operating procedures, your technology, and having the right complementary resource strategy to work with denials in a timely manner, right? We can’t get a denial today and not work it for six months, right? We have to have the technology that works it and brings it back immediately today. As things deny, the clock starts again and you have a finite time to appeal that claim,” Bridge explained of solutions needed to decrease the number of denials.

Matthew Bridge is Senior VP at AGS Health and prior to working at AGS, held leadership roles as Director and Manager at KPGM, Manager, Associate, and Analyst at Huron Consulting Group, and Analyst at Partners Healthcare. Bridge attended Curry College, where he earned a B.A. in Business Administration and Management.

Erica Franko is an experienced customer service professional who is currently SVP of Customer Success at AGS Health. Before working at AGS, Franko was Senior Manager Healthcare Provider Consumer Experience at Accenture, Beta User at The Fourth Floor, and Senior VP of Technology/Service Implementations and Advisory at nThrive, amongst other roles. Franko holds a B.A. in English Language and Literature/Letters from Penn State University and a Master of Public Health Administration, Health Policy and Management, from the University of Pittsburgh School of Public Health.

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