Brian Thompson's murder was chilling, but the social media response of this tragedy was equally shocking, if eye-opening. It shows a massive collapse of public trust in our healthcare system, a system so broken that it bankrupts families, denies life-saving care, and treats death as an acceptable cost of doing business.
While AI has the potential to streamline processes, its current use in the revenue cycle is resulting in more claim denials, payment delays, and a greater need for appeals, particularly because payers often use AI to retroactively review medical necessity determinations.
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Hospitals are facing increasingly burdensome policies from commercial insurers, leading to problems with cash flow and patient safety. Hospital executives think federal regulators need to enact stricter policies that require payers to operate on faster timelines, as well as provide more transparency into their reasons for denying claims.
Sluggish margins and high costs have created a challenging environment for provider organizations. With the number of denied claims increasing significantly over the past few years, so has the time and resources needed to manage those denials.
As the healthcare industry grapples with various challenges, from workforce shortages to complex coding intricacies, embracing AI can empower revenue cycle professionals to envision a future with reduced denials, optimized revenue, and fortified financial health.
Here are six actionable steps healthcare organizations can take to reduce their likelihood of denials and write-offs.
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Brian Gragnolati, CEO of Atlantic Health System, said that "there's a war going on between providers and payers right now." In his view, payers “are doing everything they can” not to pay providers for the care they deliver. He said insurers have greatly increased their rate of denials and are extremely reluctant to take on risk in value-based contracts.
The Labor Department recently sued UnitedHealth Group subsidiary UMR, alleging that it wrongfully denied claims for emergency room services and urinary drug screenings since 2015. UMR did not determine the medical necessity of the claims, denying them “based solely on diagnosis codes and not applying a prudent layperson standard," according to the complaint.
Hospitals and health systems, overburdened by pandemic-induced staff shortages, are in need of tech to improve workflows, reduce stress and save money. The claims denial process, which is a significant time suck and prone to errors, is ripe for innovation.