Tanya Robbins, SVP, Revenue Cycle Operations, Author at Ensemble Health Partners https://www.ensemblehp.com/blog/author/tanya-robbins/ Your modern revenue cycle solution Thu, 05 Jun 2025 19:13:58 +0000 en-US hourly 1 https://www.ensemblehp.com/wp-content/uploads/2023/10/Logo-Chevron-80x80.png Tanya Robbins, SVP, Revenue Cycle Operations, Author at Ensemble Health Partners https://www.ensemblehp.com/blog/author/tanya-robbins/ 32 32 3 Ways to Dramatically Reduce Denials https://www.ensemblehp.com/blog/stop-doing-these-3-things-to-dramatically-reduce-medical-claim-denials/ Sat, 28 Jan 2023 15:53:59 +0000 https://www.ensemblehp.com/?p=10212 With financial pressures increasing, providers can’t afford not to implement effective denial management and prevention strategies. … Read More

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Insurance companies are increasingly denying payment of medical claims received from healthcare providers. A recent report found that 11% of claims were denied in 2022, which equates to 110,000 denied claims for the average-size health system. The rate of prior-authorization denials doubled in the past year alone and request-for-information denials, which essentially serve as pre-pay audits for payers, are increasing rapidly.

With financial pressures continuing to increase and operating margins continuing to compress, providers can’t afford not to implement effective denial management and prevention strategies.

To stay ahead of increasing denial trends and ultimately reduce claim denials, here are three things to stop doing now:

1. Stop Downplaying the Importance of Scheduling

Historically, the scheduling function was primarily focused on ensuring a provider had enough time booked and was maximizing a “blocked schedule”. Now, scheduling is gateway into reimbursement. Without the right information captured and right steps taken, we can be certain of medical necessity and authorization-related denials before the patient is even treated. You should be obtaining prior authorization when necessary. Establish and maintain authorization requirement policies to make scheduling the right way the easy way.

Pro tip: Train front-end teams on the financial impact denials and claims resubmissions have on the organization so they understand the implications and importance of their roles. Ensure all teams involved understand the amount of rework their efforts will decrease by preventing denials from occurring.

2. Stop Being Blindsided by Payer Behavior

The lack of transparency in payor behavior and inconsistency in their processes continue to drive significant claim denials and make it incredibly challenging for providers to keep up. Some insurance companies, for example, use third-party vendors to issue prior authorizations but don’t inform providers of these partnerships or their requirements. This can lead to services being denied even though they appear as “no auth required” by the insurance company because the third-party itself requires an authorization – a requirement providers often don’t learn about until after the claim is denied. The amount of payor policy updates and unilateral rule changes can also make it difficult for providers to know what to expect from payers and stay compliant with their requirements beyond authorizations.

Pro tip: Engage with your payers. Ask them to outline their own processes for using third-party authorizers so your teams can appropriately manage the requirements and prevent unnecessary denials. Leverage managed care partnerships to hold payors accountable for improper authorization denials. Thoroughly review and understand the ins and outs of your payer contracts to ensure all requirements, even beyond authorizations, are met. Establish a mechanism to continually monitor for payor policy updates and contract changes to ensure your teams stay ahead, stay compliant and avoid delayed or lost revenue.

3. Stop Addressing Denials After They Occur

Develop processes and establish a strong denial prevention program that is data-based and process-minded. Data collected over time is just the starting point. Leverage initial denial and final denial data to thoroughly research accounts and look at them holistically, function by function, to identify risk areas and real root causes.

Form a hypothesis. Engage other departments to test it. Ask questions like “What is documented? What do we not see? Where are the gaps?” True root cause resolution not only requires an understanding of the actual source of denials, but also an ability to connect the right dots across the revenue cycle, clinical departments and various stakeholder groups to resolve the identified issues.

Pro tip: Make sure you’re solving the right problem, not just the perceived problem. Combine technology with expertise to build necessary logic to flag accounts with certain risk factors and build rules-based work queues to address specific issues. Form a denials prevention committee capable of analyzing denial trends, sharing results with various stakeholders and holding parties accountable for upstream issue resolution.

Key Takeaways

Merely monitoring denials is not enough.

The rate payers are denying claims continues to increase, putting millions of dollars at risk for providers each year. Providers need effective denial prevention strategies to combat these trends. As payor tactics continue to change, providers must quickly adapt to prevent unnecessary lost revenue and ensure they can continue delivering on their missions in their communities. Addressing these three critical areas will strengthen the foundation of your prevention and reimbursement program.

Are you confident in your denial prevention strategy? If not, there’s no time to waste.

Find out how Ensemble can help assess your current denial prevention capabilities and implement a sustainable program for continued success.

These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Neither Ensemble Health Partners, nor any of its employees, are your lawyers. Please consult with your own legal counsel or compliance professional regarding specific legal or compliance questions you have.

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]]> Navigating the Patient Financial Journey https://www.ensemblehp.com/blog/navigating-the-patient-financial-journey/ Fri, 14 Jan 2022 03:12:28 +0000 https://www.ensemblehp.com/?p=7394 Point of Service Collections are not just about collecting dollars, but critical information patients want and need to know. … Read More

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Point of Service Collections are not just about collecting dollars, but a critical piece of the patient financial journey, where patients can learn more about their insurance benefits and financial liabilities. This is information patients want to know when they are engaging in healthcare.  

  • 90% of patients consider pre-care price estimates to be moderately to extremely important (Source: Advisory Board’s 2018 Consumer Financial Survey) 
  • 88% of patients want to know their payment responsibility up front (Source: Ins tamed, Trends in Healthcare Payments Ninth Annual Report) 

It’s imperative that healthcare representatives are prepared to have these discussions in an informative and empathic manner. The following are three quick tips to consistently make your patient financial journey a success: 

1. Set Expectations for Staff + Patients

Healthcare is complicated and expensive. Patients do not always understand the nuances of insurance, how estimates are created or that they could receive multiple statements. Staff should be well versed in explaining benefits and informing patients on what comes next.

Often, healthcare representatives have knowledge that is specific to their own department. Outlining the flow of the patient financial journey helps staff understand how they can affect the patient experience across the continuum of care while improving point of service collections. It also gives associates the information they need to effectively convey these steps to the patient. 

Providing patients with collateral that is bright and easy to understand provides a high-level look at what to expect from a financial perspective. It is a great resource to get the financial conversation started and can be used online and/or as a handout. We recommend making the information available in multiple formats to appeal to a wider audience. 

2. Be Price Transparent

Patients have a “consumer mindset” and they do shop for healthcare. Let’s make the patient financial journey as easy as possible by following the CMS requirement that took effect on January 1, 2021. Price transparency allows patients to be more informed regarding financial liability by making prices for items and services readily available. Put your healthcare system at the top of their list by making price transparency part of your brand. Ensure your published price menu or estimation tool is easy to find, easy to use and accurate. Keep in mind your Patient Access and Pre-Access associates should also know where to find this tool, how to use it and how to troubleshoot errors if a patient encounters challenges while using it.  

3. Be Consistent

One of the biggest challenges organizations face regarding the patient financial journey is the lack of consistency. Patients are not consistently educated regarding their financial responsibility nor do organizations consistently collect their amount due. 

Use every resource available to ensure patients are informed that payment is expected before or at the time of service. Communicate through Pre-Access interactions, physician outreach, marketing collateral, websites and digital signage. 

Be sure to educate your teams across the continuum of care about how these efforts support the financial integrity of the organization. Staff should be comfortable educating patients about the organization’s credit and collection policy in addition to presenting the payment hierarchy. They should offer prompt pay discounts (if available), payment plans or financial assistance to best serve the needs of the patient. Ensure your team is consistent and set them up for success by auditing their process and removing any barriers that may keep them from having an empathic and educational financial discussion. 

Key Takeaways

The financial journey of our patients can be complicated, but it doesn’t have to be.

Patients want to be informed of their financial responsibility and healthcare teams should be prepared to guide them. Set the course for a positive experience by using this marketing collateral to communicate expectations, become educated on your own organization’s price transparency tool and encourage consistency in education and point of service collections today. These three steps will go a long way in helping your patients and staff navigate the financial journey together. 

At Ensemble Health Partners, we help providers manage complex payer regulations and adapt to evolving trends by empowering them with the data and operational expertise they need to remain compliant, avoid lost revenue and continue to deliver on their missions of providing quality care to their communities. 

These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Please consult with your own legal counsel or compliance professional regards specific legal or compliance questions you have.

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]]> Point Solutions: How Denials Impact Patient Satisfaction https://www.ensemblehp.com/blog/point-solutions-how-denials-impact-patient-satisfaction/ Wed, 12 Feb 2020 05:00:00 +0000 https://www.ensemblehp.com/2020/02/12/point-solutions-how-denials-impact-patient-satisfaction/ Providers may overlook a major reason to keep denials in check: poor denials management can lead to significant hits to patient satisfaction. … Read More

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Get Smart About Denials and Avoid a Patient Satisfaction Nightmare

Hospitals and health systems focus on preventing denials for many reasons. Perhaps they want to get tighter control over shrinking margins, preserve revenue integrity or accelerate cash. While these are valid motives, organizations often struggle most with the piece of the denial lifecycle where providers feel they have the least control: how denials impact a patient and how they may alter perceptions or the level of trust the patient population has in a care provider. Hospitals and health systems sometimes view denials management with blinders on, focusing squarely on how to stop the slow bleed monetarily. However, in doing so, providers often overlook one of the most significant reasons to keep denials in check: poor denials management can lead to significant and avoidable hits to patient satisfaction metrics.

How Patients Hear About Denials

Patients are most frequently made aware of post-service denials directly from their insurance carriers via an Explanation of Benefits (EOB) sent to the patient’s home. Since most patients are not overly familiar with how the claims process works, they may not know what the significance of an EOB is, how to read it or the practicality of what it means. Insurance companies are not great about explaining how to read an EOB, and when patients see that all or a portion of their claims have been denied, they can have a fear-based response out of concern for what that denial means for them monetarily. Even if a denial primarily affects the facility’s reimbursement, and the correspondence is only meant to inform the patient, the absence of a clear explanation can cause confusion and distress for a patient during the time when he or she should be focused on recovery.

Patients can also hear about denials from a hospital’s financial services department. A hospital may reach out to a patient to clarify and validate the information from the patient before resubmitting a claim in an effort to overturn the denial and get the patient’s claim processed for payment. This may cause patients to worry as they wonder if the claim will be processed successfully the next time.

Another scenario where a patient may become aware of or directly involved in the denials process is when organizations try to involve patients in denial disputes. In these cases, the hospital or health system may require clarification and/or verification from the patient regarding his or her insurance information. They may request that the patient complete forms to obtain plan documents from the carrier denying the benefit, or obtain medical records from medical providers the patient may have seen prior to his or her denied service(s). These interactions can be stressful because the staff member is asking the individual to revisit a matter he or she considered closed. Such discussions can lead to frustration and anxiety, especially if the patient believes the denial may increase his or her financial exposure.

The Fallout Can Escalate Quickly

When patients find out about a claim denial, they tend to see it as an issue created by the hospital, not the insurance company. Over time, if patients receive multiple notifications about denials, it can create the impression that the hospital is improperly handling their information and not protecting the patient’s financial interests. This can lead to a downward spiral where the patient starts to believe the facility struggles with billing, and the individual begins to question the validity of the invoices coming from the organization. The patient then may hesitate before making any payments because of a lack of faith, which can reduce point-of-service or post-service collections.

Disgruntled patients rarely keep their dissatisfaction a secret. Instead, they will share their displeasure with family, friends or members of their community, which can potentially spark harmful word of mouth for that hospital or system. If the friends and family members are having similar experiences, the distrust in a care provider within the community can rapidly escalate, especially if people leave damaging feedback on a health system’s website or social media platforms. Eventually, a patient may become so frustrated that he or she ultimately opts to receive care from another provider. Once an organization loses patient loyalty, it is exceedingly difficult to get back the trust and buy-in of the patient population.

So, how do you know if your denial rate is impacting patient perceptions?

Contact us here solutions@ensemblehp.com to get a full breakdown of innovative approaches your organization can take now to ensure your denial rate isn’t impacting patient perceptions and to learn more about the tell-tale signs and innovative approaches your organization can take now to squash this persistent problem.

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