Change Healthcare and HFMA partnered on a research study that analyzed the state of claims denials in the United States. It focused on understanding providers' first-pass claim rates, denials occurring from lack of pre-authorization and medical necessity processes, and pain points that are opportunities for innovation.
HFMA/Change Healthcare: Pre-Authorization and Medical Necessity Opportunities
Claims denials are a pervasive and persistent problem that ultimately affect healthcare organizations’ revenue streams and influence the quality of care. As denials occur throughout the revenue cycle, understanding strategies and innovations to prevent denials during pre-service can mitigate issues that lead to denials downstream.
Change Healthcare sponsored an HFMA research study analyzing the current state of claims denials in the United States. The study focused on understanding providers':
- first-pass claim rates;
- denials occurring from lack of pre-authorization and medical necessity processes; and
- pain-point areas that highlight opportunities to innovate.
Results show that for the majority of organizations, more than 4 percent of first-pass claims result in denials, with 51 percent noting an increase in pre-authorization and medical necessity denials. Due to complex payer rules and lack of authorization automation, providers are finding a need for standardization across health plans, including pre-authorization waivers for certain procedures and full automation in workflows in and across the hospital setting.
Download the full study here.