Payor Denials/Downgrades on the Rise

Posted by: Sarah Cartwright

Are you asking yourself, “Am I imagining this, or does it seem like denials are becoming overwhelming?” You are not alone, and you are not imagining the upward trend. Payor denials are on the rise and continue to increase more and more. These increases cost healthcare providers and facilities thousands or millions of dollars each year. Time spent trying to understand/decipher/research claim payment adjustments, denial reasons, payment reductions, etc. can be very time consuming, costly, frustrating and eat up valuable resources. On top of that, there is a specific open window of time for appeal. How does one deal with this?

Insurance companies are denying claims for many reasons some of which are based on interpretation of coding guidelines. Medical necessity not supported is one of the main denial reasons cited. Insurance companies generally send EOBs with denial reasons or denial letters; however, we have seen in the industry that some are just flat out paying a lower amount without any explanation. It seems that they manipulate the denial/downgrade process hoping that it will go unnoticed or that the practice falls short on resources, staff, or time to appeal. With the COVID pandemic and surge in patient visits, time and limited resources is a real challenge. This puts a strain on already overworked staff members. Outsourcing to specialized experts may be a cost-effective solution!

Edelberg and Associates can assist with all of this! Statistics show that approximately two thirds of denials are recoverable, and many are preventable. Getting to root causes of denials, evaluating trends, developing strategies to prevent denials are all important areas to consider in minimizing denials and maximizing revenue flow. Our team of experts has been successful in submitting appeals that result in overturning evaluation and management level denials. Should this escalate to the court level, we have participated as experts. Let us take the stress, strain, and load of denials/appeals management off of you!

Contact Edelberg and Associates for more details on how we can assist your organization!

Talk To Our Team Today

Get in touch and we'll be happy to personally assist you all the way through.

    Talk To Our Team Today

    Get in touch and we'll be happy to personally assist you all the way through.