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Key Principles for Proactive Management of Patient Denials
https://www.kaufmanhall.com/insights/article/key-principles-proactive-management-patient-denials
The proliferation of claims denials, especially by Medicare Advantage payers, has become a pressing issue for health system operations. In 2023, Medicare Advantage insurers fully or partially denied 3.2 million prior authorization requests—or 6.4% of all requests, according to a Kaiser Family Foundation (KFF) report.
The growth in denials can be partially explained by the increasing popularity of managed Medicare and Medicaid plans, but evolving payer practices, including the adoption of AI for algorithmic denials, have also contributed. Claims denials have emerged as one of the key points of payer-provider tension, and an effective claims denials management and prevention program is a powerful way for health systems to rebalance their payer relationships.
Denied claims result in reduced reimbursement, added administrative burdens, and patient and provider frustrations. Even when denials are successfully appealed and reversed—the KFF report found that in 2023, 82% of Medicare Advantage denials were partially or fully overturned—the time and resources devoted to the appeals process add to the costs of providing healthcare services. Optimizing pre-billing activities to reduce avoidable denials and improve and streamline the patient experience of care is as essential for health systems as a robust appeals strategy. This article addresses critical success factors for both preventing and appealing denials.
Preventing Claims Denials During Pre-Bill Period
Successfully preventing denials requires a centralized program across the workforce, from frontline providers to clinical and revenue cycle staff, to manage pre-bill activities by focusing on identifying the correct patient insurance information, obtaining accurate authorizations, and preventing concurrent denials while the patient is still in the facility. Utilization review nurses, attending providers, and Physician Advisors should be attentive to documenting the full state of patient acuity, while collaborating with the revenue cycle team. This team should focus on the collection and reporting of medically necessary data and documentation, which serves as the evidence payers use to evaluate prior authorization requests. When information about a patient’s condition isn’t recorded, or acknowledged in an authorization request, unnecessary denials can result.
A successful denials prevention program expands beyond the utilization management (UM) team and includes revenue cycle, and provider collaboration. Revenue cycle pre-service procedures should focus on confirming insurance benefits and securing payer authorization for planned services while collaborating with UM and referral sources. A comprehensive and proactive denials prevention program helps conveys to payers the full extent of inpatient clinical work, thanks to a collaborative effort to improve documentation.
The following list can help organize denials prevention programs across all locations, clinics and practices:
- Establish an enterprise-wide denials prevention strategy which includes a multi-disciplinary denials management committee focused on identifying denials trends, conducting root cause analyses, developing proactive denials mitigation plans, creating enhanced reporting, monitoring improvement, and communicating risk
- Establish proactive revenue cycle, UM, pre-certification, and peer-to peer workflows procedures to confirm completion of payer requirements prior to scheduled services and discharge
- Ensure patients are financially cleared through implementation of pre-service protocols, including enhanced medical necessity process for outpatient services, authorization defer and delay procedures to reduce rework and avoidable denials
- Identify pre-bill edits to increase “clean claim” efficiency, reducing initial denials and expediting reimbursement
- Deliver education to providers, care management, and nursing teams on key observation concepts, such as clinical documentation improvement, patient status documentation, medical necessity documentation and orders for the Two Midnights rule, and payer reimbursement methodologies
Pursuing Post-Bill Appeals, Reversals and Payer Escalation
A strong denials management and prevention program should include a robust post-bill appeals program with skilled coding, clinical and technical resources. A targeted and strategic appeal process can result in improved overturn rates and increased reimbursement. Appeal letters which are supported by clinical facts, payer policies, and a summary of key components relevant to each case and the associated denial increase the likelihood of success.
Components of the appeal program should include the following:
- Guidelines for when to appeal based on potential success by payer and appeal level
- Reviews of upheld appeals for second and third level appeals based on strategy by payer
- Trends for all upheld appeals by reason and by payer
- Dashboard for tracking denials activities
- Appeal letter writing guidelines and tips to support
- Evaluation process for existing payer escalation workflows, tools and payer communication strategies with consideration for payer
- Process to measure and monitor overturn rates and improvement opportunities
The collaboration with managed care is vital to the success of the denials management/prevention program. A formal payer escalation process which facilitates transparency between the payer and provider can result in improved relations and a reduction in initial denials. Successful denials management/prevention payer escalation programs are strategic and focus on addressing unfair/incorrect denials and establishing clear bi-directional reporting and communications. These programs can result in improved contract negotiations and reduce incorrect denials.
Artificial Intelligence (AI) can support the post-bill appeals process and can be especially relevant when developing a strategy to combat denials. Not only are payers increasingly using AI to trigger denials, but health systems can also deploy AI to write appeal letters, analyze denial trends, and summarize medically necessary documentation. Although algorithmic denials have become a source of frustration for providers and patients, health systems can also deploy AI to their defense. While payers are often better positioned to devote AI resources to claims, a little bit of investment from health systems, deployed effectively, can go a long way toward evening the playing field.
Closing Thoughts and Seven Questions to Consider
A formal denials management and prevention program is essential to obtaining proper reimbursement for the care provided and reducing rework across the enterprise. A strong program should also improve the patient’s experience of care: ideally, a patient should not need to interact with or hear from their provider between scheduling an appointment and checking in.
Denials management and prevention programs should be led by multi-disciplinary committees and focus on reducing avoidable denials and rework. Reducing denials requires the implementation of a multi-disciplinary program and collaboration between UM, revenue cycle, clinical documentation improvement, managed care, clinical operation and providers.
Health systems reassessing their claims denials program should consider these questions:
- Do you have a reactive or proactive denials management strategy in place?
- Does your denials strategy include multi-disciplinary team representation?
- What reporting/tools are currently being used to track and manage denials?
- What are your top five denial categories and what is being done to address the root cause of these denials?
- How are avoidable denial risks managed, communicated and monitored?
- Have you implemented a comprehensive denials management strategy with a multi-disciplinary committee?
- Are the system’s internal resources and expertise sufficient for addressing identified challenges, or should the system seek external partners to implement changes?
The State of Trust in Public Health in America
https://www.kaufmanhall.com/insights/infographic/state-trust-public-health-america
In light of the recent confirmation of Secretary Kennedy to lead HHS and new survey data on trust in public health, this graphic highlights Americans’ declining positive perception of public health officials. Among respondents’ personal doctors, the CDC and their state and local public health officials, trust in all three, regardless of political identification, has decreased from June 2023 to January 2025.
Respondents trusted their doctors more than public health officials, and there is less difference by political identification. In 2025, only 61% of surveyed Americans reported that they trusted the CDC. That prevalence drops to 39% among Republicans and increases to 85% among Democrats.
Another important public health indicator, the percentage of kindergarteners with vaccine exemptions, also illustrates the challenging place in which public health officials find themselves. During the 2023-2024 school year, about 3.3% of kindergartners received an exemption, an increase from 2022-2023 that still does not provide a complete picture. Exemption rates vary widely by state, with 6 states having exemption rates more than double the median. These differences are a reflection of how easy it is to receive an exemption in some states rather than a clear trend.
The shift also underscores how easily an outbreak could occur in some states. Alarmingly, the perceived importance of vaccines has dramatically decreased, from 94% in 2001 to 69% in 2024.
We will have to wait and see what Kennedy, long considered a vaccine skeptic, does regarding vaccines, but amid immense distrust in the healthcare system, providers’ role of giving thorough, honest information to their patients is more important than ever.
The Implications of Losing Access to Tax-Exempt Financing
On January 17, 2025, a list of potential cost reductions to the federal budget was released by Republicans on the House Budget Committee. The list is long and covers the federal budget waterfront, but it spends considerable time focusing on reductions to healthcare spending. This laundry list of cost reductions is important because the highest priority of the Trump administration is a further reduction in federal taxes. A reduction in taxes would, of course, reduce federal revenue; if federal expenses are not proportionately reduced then the federal deficit will increase. When the deficit increases then the federal debt must increase and at that point the overall impact on the American economy becomes concerning and possibly damaging. There has already been much public speculation as to how the Federal Reserve might react to such a scenario.
It is not possible right now to highlight and describe all of the House budget proposals, but one proposal absolutely stands out: The suggestion to eliminate the tax-exempt status for interest payments on all municipal bonds, or potentially in a more targeted manner, for private activity bonds, including those issued by not-for-profit hospitals. Siebert Williams Shank, an investment banking firm, described the elimination of tax exemption for municipal bonds as “the most alarming of the proposed reforms impacting non-profit and municipal issuers.”[1] This is certainly true for hospitals, since over the past 60 years the growth and capability of America’s hospitals has been substantially constructed on the foundation of flexible and relatively inexpensive tax-exempt debt. Given all of this, it is not too early to begin speculating on the impact of the elimination of tax-exempt debt on hospital finances and strategy.
We should also point out that a separate topic is under discussion, related to the potential loss of not-for-profit status for hospitals and health systems. Such a maneuver could potentially expose hospitals to income taxes, property taxes, and higher funding costs. For now, that is beyond the scope of this blog but may be something we write about in future posts.
Below is a series of important questions related to the elimination of tax-exempt financing and some speculations on the overall impact:
- What immediately happens if 501(c)(3) hospitals lose the ability to issue tax-exempt bonds? Let’s treat fixed rate debt first. Assume for now that only newly issued debt would be affected and that all currently outstanding tax-exempt fixed rate debt would remain tax-exempt. We could see an effort to apply any changes retroactively to existing bonds, but we view that as unlikely. Therefore, our current expectation is that outstanding fixed-rate debt would not see a change in interest expense.
However, it is possible that outstanding floating rate debt would immediately begin to trade based on the taxable equivalent. Historically the tax-exempt floating rate index trades at about 65% of the taxable index. The difference between the tax-exempt and taxable floating rate indices in the current market is 175 basis points. For every $100 million of debt, this would increase interest expense by $1.75m annually. - How would new hospital debt be issued? New debt would be issued in the municipal market on a taxable basis or in the corporate taxable market. The taxable municipal market would need to adapt and expand to accommodate a significant level of new issuance. The concern in the corporate taxable market is greater. Currently, the corporate market requires issuance of significant dollar size and generally the issuer brings significant name recognition to the market. Many hospitals may have difficulty meeting the issuance size of the corporate debt market and/or the necessary market recognition. As such, smaller and less frequent issuers would expect to pay a penalty of 25-50 basis points for issuing in the corporate market.
- If tax-exempt debt goes away will certain hospitals be advantaged and others disadvantaged? Larger hospitals with national or regional name recognition that issue bonds with sufficiently large transaction size and frequency will likely borrow at better terms and lower rates. Smaller- to medium-sized hospitals may find borrowing much more difficult, and borrowing may come with more problematic terms and/or amortization schedules and likely higher interest rates.
- Will borrowing costs go up? The cost of funds for new borrowings would increase for all hospital borrowers. For a typical A-rated hospital, annual interest expense would increase by approximately 30%. For example, in the current market, on $100 million of new debt, average annual interest expense would increase by $815,000 annually.
- Will debt capacity go down? All other things being equal, interest rates will go up and hospital debt capacity will go down. Also, if the taxable market shortens amortization schedules, then that will decrease overall debt capacity as well.
- What would the impact of the elimination of tax-exempt debt be on synthetic fixed rate structures? Hospitals have long employed derivative structures to hedge interest rate risk on outstanding variable rate bonds and loans. The loss of tax-exemption for outstanding variable rate bonds and loans would precipitate an adjustment to taxable rates, but corresponding swap cash flows are not designed to adjust. Interest rate risk is hedged, but tax reform risk is not. The net effect to borrowers would be an increase in cost similar to the cost contemplated above for variable rate bonds.
- What are the rating implications of the elimination of the tax-exempt market? Rating implications will be varied. Hospitals with strong financial performance and liquidity are likely to absorb the increased interest expense of a taxable borrowing with little to no rating impact. In fact, over the past decade, many larger health systems in the AA rating categories have successfully issued debt in the taxable market without rating implications despite a higher borrowing rate. Even amid the pandemic chaos of 2021, numerous AA and A rated systems issued sizable, taxable debt offerings to bolster liquidity as proceeds were for general corporate purposes and not restricted by a third-party, such as a bond trustee.
Lower-rated hospitals with modest performance and below-average liquidity will be at greater risk for a downgrade. These hospitals may not be able to absorb the increased interest expense and maintain their ratings. While interest expense is typically a small percentage of a hospital’s total expenses, it is a use of cash flow.
We do not anticipate the rating agencies will take wholesale downgrade action on the rated portfolio as there would likely be a phase-in period before the elimination occurs. Rather, we expect the rating agencies will take a measured approach with a case-by-case evaluation of each rated organization through the normal course of surveillance, as they did during the pandemic and liquidity crisis in 2008. A dialogue on capital budgets and funding sources, typically held at the end of a rating meeting, would be moved to the top of the agenda, as it will have a direct impact on long-term viability. - How would the loss of the tax-exempt market impact the pace of consolidation in the hospital industry? If a hospital cannot afford the taxable market, then large capital projects would need to be funded through cash and operations. This inevitably will limit organizational liquidity, which will lead to downward rating pressure. Some hospitals, in such a situation, will be unable to both fund capital and adequately serve their local community and, therefore, will need to find a partner who can. We anticipate that the loss of the tax-exempt bond market will lead to further consolidation in the industry.
Let’s indulge in one last bit of speculation. What is the probability that Congress will pass legislation that eliminates tax-exempt financing? Sources in Washington tell us that it is premature to wager on any of the items put forth by the Budget Committee. And it should be noted that over the years the elimination of tax-exempt financing has been proposed on several occasions and never advanced in Congress. However, one well-informed source noted that as the tax and related legislation moves forward, there is likely to be significant horse-trading (especially in the House) to secure the necessary votes to pass the entire package. What happens during that horse-trading process is anybody’s guess. So the best advice to our hospital readership right now is to not take anything for granted. But be absolutely assured that the maintenance of tax-exempt financing is an essential strategic component for the successful future of America’s hospitals.
Implications of the National Hospital Flash Report for Hospital Operations
For the past six years, Kaufman Hall has been publishing its monthly National Hospital Flash Report, which is designed to provide a pulse on the health of the healthcare industry and to highlight meaningful and pertinent trends for hospital and health system leaders. The data that powers the report is taken from over 1,300 hospitals, which are reflective of all geographic locations, hospital sizes and types. To ensure the content is digestible and understandable, Kaufman Hall aggregates the data into larger cohorts and measures a select set of key metrics that are most important for understanding the health of the industry. Industry groups and system leaders use these reports both for peer review purposes but also to paint an overall story for their boards and communities.
Through a detailed review of the Flash Report data, each month Kaufman Hall develops findings that healthcare leaders may find instructive as they determine how to adjust to changing market conditions. In 2024 it was reasonably obvious that there was a widening divide between the highest performing hospitals and the lowest performers. While a significant cadre of hospitals and health systems have recovered to pre-Covid financial success, 37% of American hospitals continue to lose money.
We are often asked what the successful hospitals are doing—and importantly—what the data tell us about those that are less successful. Using 2024 data, we have drawn two important conclusions around the role of leading management teams and what separates their organizations from others.
These teams have:
- A sophisticated and balanced approach to the management of departmental performance: and
- An understanding of the management of shared service costs.
A sophisticated and balanced approach to the management of departmental performance
It turns out that current data demonstrate that the management of departmental performance is critical to overall hospital financial performance but in a more nuanced manner than expected.
Our analysis was conducted as follows:
- First, we looked at data across hospitals nationwide to understand the difference in departmental performance between top and bottom performing hospitals.
- Second, we ranked each department in a hospital from 0 to 100, with 100 representing the best performance based on expense per unit of service.
- Third, we then grouped all hospitals based on their bottom-line operating margin into three cohorts: those hospitals that fell into the bottom quartile of financial performance, those between the bottom and top quartile, and those in the top quartile.
- Finally, we created a histogram of the average composition of departmental performance across each of the three margin cohorts.
The findings demonstrate that organizations with top financial performance have departmental results that look like a normal curve around the median. Said more simply, in top-performing hospitals the number of lower-performing departments is roughly equal to the number of higher-performing departments, with most departments operating near the national departmental medians. In contrast, hospitals with the lowest financial performance show a much greater number of departments operating with high cost per units of service and a few departments that operate extremely efficiently.
It appears that poorer performing hospitals focus on the management of the largest clinical and nursing areas. These are the departments that tend to be the “easiest” to manage because they are the “easiest” to benchmark. But the data show that these same hospitals tend to have poor performance over the remainder of the departments, which leads to poor financial results for the total hospital.
Hospitals with top quartile financial performance tend to manage all departments as close to the benchmark median as possible. Such a result means spending more managerial time on the harder to manage departments, especially those departments that are more “unique” and where overall performance is harder to characterize and benchmark.
The observations that can be drawn here are important and as follows:
- First, oversight and management of individual departments is critical to the financial success of the entire hospital or system.
- Second, the overall organizational structure of departmental administration is critical as well. The more complicated your departmental structure and the more individual departments you maintain and administer, the more difficult it will be to manage a majority of departments to “median” results.
The data suggest a perhaps unexpected operational conclusion. The achievement of median national departmental benchmarks is leading to overall positive hospital financial operating margins. This outcome offers significant budgeting advice and over the course of a fiscal year should prove to be a remarkably useful administrative lesson.
Understanding the management of shared service costs
Given the growing costs of shared services and related overhead, Kaufman Hall wanted a closer look at how well hospital organizations were scaling shared service costs related to the organization’s size. Unexpectedly, shared service costs were not highly correlated to the size of the hospital or hospital system. This suggests that the management of shared service costs on a per unit basis is difficult and that this aspect of expense management requires diligent focus to enact and sustain cost change. Our data often indicates a wide variation of cost performance among shared services of similar types within different large organizations. This suggests that standardization of such services is not well developed and that there may be a certain level of wishful thinking that increases in organizational size will automatically correlate to lower per unit costs.
The data did indicate, however, that larger organizations can achieve higher performance over smaller organizations relative to shared service expenses. This is an indication that size can be leveraged for superior performance but that such results are not automatic. The takeaway here is that the total spend for shared service functions is very substantial and growing. In that regard, it is most important to proactively address expenses in these areas, build appropriate management plans, and understand how to focus on the right buttons and levers. To the extent that organizations are assuming that growth (both organic and inorganic) will create economies of scale with the overall shared service apparatus, the data demonstrate that such an outcome is possible but only with strong planning and execution.
Operating hospitals in 2025 is flat-out hard and likely to get harder over the year. Hospital executives right now should use every managerial advantage available. A close look at the National Hospital Flash Report data identifies important relationships that provide for a more nuanced and sophisticated operation of both individual departments and the bundle of shared services. The data clearly demonstrate that better results in both these areas will lead to improved financial performance within the hospital overall. The data also indicate key managerial strategies that will lead to such improvement.
The Perfect Storm facing the Healthcare Workforce: Eight Current Issues frame the Challenge
Tonight at midnight, thousands of federal workers face the possibility their jobs will be eliminated as part of the Department of Government Efficiency (DOGE) federal cost reduction initiative under Elon Musk’ leadership. Already, thousands who serve in federal healthcare roles at the NIH, CDC and USAID have been terminated and personnel in agencies including CMS, HHS and the FDA are likely to follow.
The federal healthcare workforce is large exceeding more than 2.5 million who serve agencies and programs as providers, clerks, administrators, scientists, analysts, counselors and more. More than half work on an hourly basis, and 95% work outside DC in field offices and clinics. For the vast majority, their work goes unnoticed except when “government waste” efforts like DOGE spring up. In those times, they’re relegated to “expendables” status and their numbers are cut.
The same can be said for the larger private U.S. healthcare workforce. Per the U.S. Bureau of Labor Statistics, industry employment was 21.4 million, or 12.8% of total U.S. employment in 2023 and is expected to reach 24 million by 2030. It’s the largest private employer in the U.S. economy and includes many roles considered “expendable” in their organizations.
Facts about the U.S. healthcare workforce:
- More than 70% of the healthcare workforce work in provider settings including 7.4 million who work in hospitals.
- More than half work in non-clinical roles.
- Home health aides is the highest growth cohort and hospitals employ the biggest number (7.4 million).
- 29% of physicians and 15% of nurses are foreign born, almost three-fourths of the workforce are women, two-thirds are non-Hispanic whites, and the majority are older than 50.
- Its licensed professions enjoy public trust ranking among Gallup’s highest rated though all have declined:
| % 2023 | ‘19-‘23 | ’23 Rank | % 2023 | ‘19-‘23 | ’23 Rank | ||
| Nurses | 78 | -7 | 1 | Pharmacists | 55 | -9 | 6 |
| Dentists | 59 | -2 | Psychiatrists | 36 | -7 | 9 | |
| Medical doctors | 56 | -9 | 5 | Chiropractors | 33 | -8 | 10 |
The Perfect storm
The healthcare workforce is unsteady: while stress and burnout are associated with doctors and nurses primarily, they cut across every workgroup and setting.
Eight fairly recent issues complicate efforts to achieve healthcare workforce stability:
Increased costs of living:
Consumers are worried about their costs of living: it hits home hardest among young, low-income households including dual eligible seniors for whom gas, food and transportation are increasing faster than their incomes, and rents exceed 50% of their income. The healthcare workforce takes a direct hit: one in five we employ cannot pay their own medical bills.
Slowdown in consolidation:
The Federal Trade Commission’s new pre-merger notification mandate that went in effect today essentially requires greater pre-merger/acquisition disclosures and a likely slowdown in deals. Organizations anticipating deals might default to layoffs to strengthen margins while the regulatory consolidation dust settles. Expendables will take a hit.
Uncertainty about Medicaid cuts:
In the House’ budget reconciliation plan, Medicaid cuts of up to $880 billion/10 years are contemplated. A cut of that magnitude will accelerate closure of more than 400 rural hospitals already at risk and throw the entire Medicaid program into chaos for the 79 million it serves—among them 3 million low-hourly wage earners in the healthcare workforce and at least 2 million in-home unpaid caregivers who can’t afford paid assistance. The impact of Medicaid cuts on the healthcare workforce is potentially catastrophic for their jobs and their health.
Heightened attention to tax exemptions for not-for-profit hospitals:
Large employers sent this recommendation to Congressional leaders last week as spending cuts were being considered: “Nonprofit hospitals, despite their tax-exempt status, frequently prioritize profits over patient care. Many have deeply questionable arrangements with for-profit entities such as management companies or collections agencies, while others have “joint ventures” with Wall Street hedge funds or other for-profit provider or staffing companies. Nonprofit hospitals often shift the burden of their costs onto taxpayers and the communities they serve by overcharging for health care services, or abusing programs intended to provide access to low-cost care and prescription drugs for low-income patients. By eliminating nonprofit hospital status, resources could be more evenly distributed across the healthcare system, ensuring that hospitals are held accountable for their charitable care both to their communities and the tax laws that govern them.” Pressures on NFP hospitals to lower costs and operate more transparently are gaining momentum in state legislatures and non-healthcare corporate boardrooms. Belt tightening is likely. Layoffs are underway.
Heightened attention to executive compensation in healthcare organizations:
Executive compensation, especially packages for CEO’s, is a growing focus of shareholder dissent, Congressional investigation, media coverage and employee disgruntlement. Compensation committee deliberations and fair market comparison data will be more publicly accessible to communities, rank and file employees, media, regulators and payers intensifying disparities between “labor” and “management”.
Increased tension between providers and insurers:
Health insurers are now recovering from 2 years of higher utilization and lower profits; hospitals did the same in 2022 and 2023. Neither is out of the woods and both are migrating to tribal warfare based on ownership (not-for-profit vs. investor owned vs. government owned), scale and ambition. Bigger, better-capitalized organizations in their ranks are faring better while many struggle. The workforce is caught in the crossfire.
Increased pressure on private equity-backed employers to exit:
The private equity market for healthcare services has experienced a slow recovery after 2 disappointing years peppered by follow-on offerings in down rounds. Exit strategies are front and center to PE sponsors; workforce stability and retention is a means to an end to consummate the deal—that’s it.
The AI Yellow Brick Road:
Last and potentially the most disruptive is the role artificial intelligence will play in redefining healthcare tasks and reorganizing the system’s processes based on large-language models and massive investments in technology. Job insecurity across the entire healthcare workforce is more dependent on geeks and less on licensed pro’s going forward.
These eight combine to make life miserable most days in health human resource management. DOGE will complicate matters more. It’s a concern in every sector of healthcare, and particularly serious in hospitals, medical practices, long-term and home care settings.
‘Modernizing the healthcare workforce’ sounds appealing, but for now, navigating these issues requires full attention. They require Board understanding and creative problem-solving by managers. And they merit a dignified and respectful approach to interactions with workers displaced by these circumstances: they’re not expendables, they’re individuals like you and me.
HENRY KOTULA 