Complex Health Insurance Denials:

5 Key Takeaways Every Hospital Revenue Cycle Executive Must Know

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The Scope

Every year, health plans are finding new and creative ways to underpay or deny payment to hospitals. This trend is causing complex claim denials to become an increasing financial and administrative burden for health systems throughout the country.

Typically, these claims consist of hospital charges exceeding $100,000 or an expected reimbursement exceeding $50,000. Complex denial or underpayment reasons may include:

• Managed care contract interpretation issues
• Reference pricing plan limitations
• Pre-and post-payment level of care and DRG reviews
• Coordination of benefits issues
• General medical necessity denials
• Health plan policy issues

Combatting these complex denials requires substantial industry expertise, extending beyond the norm for resolving routine payment issues.


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