I just got finished reading an article published in Stat News (www.statnews.com) entitled, “Unnecessary insurance claim denials compromise patient care and provider bottom lines.” At our last Board meeting of the year, we take a moment to review with our Board members what the critical issues for the next year will be. In 2023, our Board suggested that patient access and insurance denials would be those issues in 2024.

I am not writing this article from one perspective. I know that hospitals try their best to produce a “clean claim” in the hopes that these claims will navigate insurer payment systems with little delay. Hospitals and all health care providers are depending on these reimbursements to fund continued operations.

I also know that insurers, representing the interests of their members and wanting to keep those members for the long term, want that process to work in a way that protects the interests of those members by providing the needed due diligence to ensure that, in this world fraught with bad actors, legitimate claims are paid timely.

While there is nothing new about this age old challenge of competing interests, it seems that in this time of increasing use of technology to assist in the both the preparation of these claims and the processing of the claims by insurers, we seem to be getting further off the “rails.” Health care providers are growing increasing frustrated with the numbers and economic impact of these denied claims and many are resorting to more extreme measures to exact payment.

Who wins in this battle, I do not think anyone. The patient does not win as they are now brought into the fray. The provider does not win, as they have to invest more and more resources leading to successful adjudication of the claim. The insurer does not win as they try to explain to their members why the claim for services, which the member received, is not paid. And, certainly the courts don’t win as their docket of cases multiplies.

Let us take a moment and briefly talk about this challenge to the health care system.

In the article mentioned above written by Michael J. Alkire. He surveyed hospitals to get a picture of claims for 2022 and the returned data was weighted by the acute bed capacity of the hospital. I am not attesting to either the accuracy of the method or even the derived results. What is helpful is to see these results as one tool used to help identify the size of the challenge.

In summary, the author suggests that, overall, 15 percent of all claims submitted for payment are denied. He then looks at the type of payer and determines that Medicaid managed care plan have the highest denial rate, followed by Medicare Advantage, Managed Medicaid, Commercial, and, last, Medicare. He also looks at the average dollar threshold above which receiving a denial is more common.

There are also studies that cut similar data in a way that allows the reader to see those denials by insurer. You can look those up and see for yourself as I see the publishing of that information here as counterproductive. What we do see in the growing weight of data is that there is a disconnect between medical providers and insurers that needs to be repaired. Again, no one wins if we continue down this path.

Therefore, we have listened to our Board and we are in the planning stages for a program to be held in early November that looks at this challenge and with the intent that attendees will leave the program with additional tools to put into their toolbox that will move us forward in the discussions between healthcare providers, insured, and insurers. To continue to do what we are doing today is not sustainable and invites federal and state oversight. Those types of political solutions rarely get us to a win-win.