Premier Survey: 15 P.c of Claims to Non-public Payers Are Initially Denied

A current survey of members by healthcare enchancment group Premier discovered that almost 15 p.c of all claims submitted to personal payers for reimbursement are initially denied, together with many which are pre-approved via a previous authorization course of. 

Premier and 118 of its member organizations despatched a letter to the Facilities for Medicare & Medicaid Companies (CMS) highlighting the outcomes of the survey of hospitals, well being methods and post-acute care suppliers that they are saying reveal the scope of fee delays and denials by non-public payers. 

Premier famous that survey respondents reported critical considerations with fee delays and denials, which they are saying adversely impression sufferers’ well timed entry to medically obligatory care and impose pointless administrative and monetary burdens on suppliers.

Premier performed a voluntary, nationwide survey of member hospitals and well being methods from October 10-December 31, 2023. Respondents represented 516 hospitals throughout 36 states, accounting for 52,123 acute care beds. Medicare Benefit (MA) and Medicaid well being plans denied preliminary claims submissions at higher-than-average charges of 15.7 p.c and 16.7 p.c, respectively. Denials tended to be extra prevalent for higher-cost therapies, with the common denials throughout payer sorts pegged to expenses of $14,000 or better.

Regardless of vital charges of denials on preliminary claims submissions, the survey discovered that 52.7 p.c of MA claims denials have been finally overturned, and the claims paid. Nevertheless, hospital and well being system survey respondents that fought the denials did so at a median administrative price of $47.77 per declare for MA claims and $43.84 per declare on common throughout non-public insurance coverage sorts. This determine doesn’t embody the prices related to added scientific labor, which the American Medical Affiliation estimates provides $13.29 to the adjudication price per declare for a common inpatient keep and $51.20 to the price of inpatient surgical procedure.

The letter supplies suggestions on coverage adjustments to advance the wants of sufferers enrolled within the Medicare Benefit (MA) program and the suppliers who look after them.

Particularly, the organizations urge CMS to: 
• Acquire knowledge on fee denials and delays by MA plans;
• Return to its previous coverage of weighting affected person expertise and entry measures extra closely within the MA Star Rankings methodology, empowering beneficiaries to carry their well being plans financially accountable;
• Take enforcement motion towards MA plans that fail to abide by the protection guidelines of Medicare; 
• Work expeditiously to implement its current regulatory adjustments to streamline prior authorization necessities within the MA program; and
• Require protection dedication critiques to be performed by physicians of the identical specialty for the service being reviewed – not a cost-containment algorithm. 


The letter additionally calls on policymakers to stipulate that claims authorized underneath an digital prior authorization will not be artificially delayed or denied and for Congress to make sure CMS has the statutory authority wanted to implement its rules, together with by holding oversight hearings to fight dangerous actors on this house.