A current trend in the Healthcare industry is the increasing volume of inpatient claims denied by payers based on lack of medical necessity. While Medicare offers detailed payer categories compared to other providers, they also reject the highest number of shares. However, from 2021 to 2022, the inpatient claim denial saw a rise of 18.5% across all payers. So, in what ways can healthcare providers combat this trend and ensure that their revenue cycle and care management team are aligned?
Colleen Hall, a managing principal of the healthcare group at Crowe, states, “One step that providers can take to try to prevent these reimbursement issues is to implement a physician adviser program to verify the patient status and allow for peer-to-peer reviews to be completed when payors off them,” said Hall. “This could help alleviate the administrative burden placed on them to defend the level of care, so hospitals can allocate more of their resources to caring for their patients.”
Shearwater Health offers effective Utilization Management programs based on providing the proper patient care at the right time to reduce the cost of claims. While some UM programs focus on denials (prioritizing cost savings over patient care), they often add to the cost of a claim. When a UM program’s principal focus is quality of care, early intervention is more likely to happen thus avoiding more costly procedures down the line. Remote clinicians who can take on the administrative workload allow on-site clinicians more time to tend to patients more intently. Ideally, this means less claims that could be denied based on lack of medical necessity as medical experts are able to provide more thorough care. Additionally, having remote clinicians who can thoroughly evaluate a patient’s benefits and keep them up to date on the status of their medical bills is a huge aid in reducing potential claim denials.
A successful utilization management program revolves around highly skilled, experienced clinicians who can see the bigger picture, prioritize quality, and improve patient care. With Shearwater, you can scale your clinical teams, improve quality scores, and reduce costs.
About Shearwater Health
Because of a shortage of clinicians, it’s often difficult to scale healthcare organizations. Shearwater Health provides teams of remote and onsite clinicians that expand the size and impact of clinical teams so that clients can focus on internal teams practicing at the peak of their license. From bedside to back-office, there are over 4,000 Shearwater clinicians solving medical and administrative problems every hour of every day all over the world. Shearwater combines clinical expertise with Six sigma process excellence and RPA technology to improve healthcare outcomes. www.shearwaterhealth.com
