Episode Overview:

In this episode, we dive into the latest trends and challenges in the world of healthcare denials, focusing on payer-driven issues and solutions. The discussion spans denial trends, specifically around inpatient DRG downgrades, and the nuances of navigating denials and claim processes. We also cover technology gaps, regulatory shifts, and emerging solutions in the revenue cycle, particularly for claims with no response and payer-driven reimbursement barriers.

Key Topics Discussed:

• DRG Denials and Humana’s Query Compliance: Robin brings up a denial trend where Humana denies inpatient DRG claims based on “non-compliant queries,” prompting insights on how other professionals are tackling this issue.

• Technology for Claims Without Response: A compelling case is made for creating automation around claims that have not received a denial or payment. This includes potential decision trees for follow-up actions on claims without EDI data to improve efficiency.

• Prior Authorization and Payer Challenges: The conversation highlights the industry’s struggle with prior authorization, arguing that innovation should focus on reducing the overall burden rather than automating current processes, which only minimally alleviate providers’ challenges.

• The Telehealth Dilemma Post-2024: With telehealth flexibilities set to expire at the end of 2024, Whitney raises concerns over how practices primarily based on telehealth services, especially those offering behavioral health, will adapt. Regulatory changes are dissected, with possible strategies suggested to navigate this impending change.

• Innovations in Denial Management: Attendees discuss tools for denial tracking and payer insights, like Cleopatra Queen of Denial, a software solution developed to trend denial types across categories for better negotiation leverage.

• Building Technology That Truly Helps the Revenue Cycle: A call is made for technology that directly addresses payer-driven issues, rather than administrative burdens, suggesting a focus on innovation that simplifies payer policies and medical necessity criteria.

• Professional Events and Resources: The episode includes a discussion on upcoming events, like Joe Rivett’s denial forum, offering listeners insight into where they can learn more about denial management, payer perspectives, and effective appeals writing.

Listeners are encouraged to reach out and share their own experiences with denial management challenges, particularly around DRG downgrades and telehealth changes, fostering a community of shared insights and solutions.