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The Rising Need for Claim Denial Management




In the wake of the COVID-19 pandemic, hospital systems and their Chief Financial Officers (CFOs) are facing unprecedented financial pressures highlighting the growing need for more advanced and efficient revenue cycle management. The latest predictions from the Centers for Medicare & Medicaid Services (CMS) estimate that in 2025, healthcare spending in the US will reach a staggering $5.19 trillion. 1


Despite this rise in spending, the Congressional Budget Office (CBO) has warned that the average profit margin for hospitals could drop to a mere 3.3% by 2025.2 Although these deficits can be attributed to a number of factors, the rapidly accelerating provider claims denial rate plays a heightened role. In 2021, nearly 17% of in-network provider claims were denied.3 The elaborate claim processing and payment takeback schemes utilized by health insurance companies cost physicians and hospital systems over $1.6 billion a month.4


Healthcare systems, CFOs, and their revenue cycle staff face an increasingly challenging financial conundrum in addressing these issues. The intricate and transient nature of the regulations, provider services agreements, coding, prior-authorization, and In/Out-of-Network reimbursement rates requires specialized knowledge and skill to effectively manage denials.


Abril Law has over thirty years of experience in healthcare reimbursement. Our team of attorneys and dedicated staff are experts in all phases of revenue cycle and provider claims denial management, ensuring physicians and hospitals alike are adequately compensated for their services. We assist a diverse cross-section of healthcare providers including, but not limited to, multi-facility acute care, rehabilitation, and behavioral hospital systems, physician practices, pathologists, cardiologists, radiologists, and laboratories.


Our experienced attorneys provide guidance and counsel on a variety of healthcare reimbursement matters including coding, contractual, and precertification denials, Out-of-Network denials, third-party liability claims, self-pay patient advocacy, workers’ compensation, ERISA, and complex claims. For more information on how the latest healthcare revenue figures affect provider reimbursement for services, or for representation in rate negotiations or arbitration proceedings, contact Abril Law for a free consultation.


 

Citations:

[1] McGough, Matthew, Meghan Salaga, Cynthia Cox Twitter, and Krutika Amin. “How Much Is Health Spending Expected to Grow?” Peterson-KFF Health System Tracker, October 11, 2023.

[2] Hayford, Tamara, Lyle Nelson, and Alexia Diorio, 04 Projecting hospitals’ profit margins under several illustrative scenarios § (2016).

[3] Karen Pollitz, Justin Lo. “Claims Denials and Appeals in ACA Marketplace Plans in 2021.” KFF, March 29, 2023.

[4] Robeznieks, Andis. “Health Systems Plagued by Payer-Takeback Schemes, 110,000 Denials.” American Medical Association, January 19, 2023.


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