Fall 2023

Editor’s Note: No One Is Denying the Rise of Denials
By Kate Jackson
For The Record
Vol. 35 No. 4 P. 4

Eavesdrop on conversations with HIM professionals these days and the only phrase you’re likely to hear as often as “artificial intelligence” is “claims denial.” Everyone is concerned about it, talking about it, and trying to take aim against it.

The Journal of AHIMA last year reported that denial rates have increased more than 20% in the previous five years, and according to the American Medical Association, from 2021 to 2022, denials affected 11% of claims.

A survey by the American Hospital Association found that staff of 95% of hospitals and health systems spend more time obtaining prior authorization approval, and 84% of respondents indicate that the cost of compliance with insurer policies is rising, while none says it’s decreasing. What’s more, the same survey noted that half of initial claims and 62% of prior authorization denials are overturned on appeal. And when appeals are unsuccessful, 35% of hospitals and health systems say they lose $50 million or more in unpaid claims.

Not surprisingly, there are rising tensions between providers and payers.

That’s why denials are the topic of not one but two features in this issue. Beth Friedman, a senior partner at FINN Partners, gets expert opinions from a broad range of HIM experts to offer eight ways providers can protect themselves in the new era of payer denials. Kacie Geretz, revenue cycle management manager at Nym, discusses the complexity of payer policy changes and offers proactive strategies for improving compliance and preventing denials.

Also in this issue, Eric McGuire, senior vice president of medical coding and clinical documentation improvement service line and corporate strategy at AGS Health, outlines seven factors for a successful risk adjustment program; Bart Howe, CEO at Health-Mark Group, details the importance of a clearly defined record set; and freelance health writer Elizabeth Goar addresses the documentation challenges created by the upcoming update of CMS’s hierarchical condition categories.

Another key topic threaded through three articles in this issue is the importance of teamwork and inclusion. Richard Amelio and Todd Goughnour of e4health examine the importance of IT and HIM collaboration during major system change; and freelance contributor Susan Chapman reports on a joint project between AHIMA and the Sequoia Project to advance health IT interoperability.

Finally, Sese Bennett, a virtual chief information security officer for CereCore Advisory Services, looks at the association between one of the most significant threats to health institutions—cybersecurity—and one of the most pervasive problems in health care—burnout.

— Kate Jackson

kjackson@gvpub.com