Rising Rate of Claims Denials Suggests Need for Better Payer-Provider Relations

It is getting harder and harder for health care providers to get claims approved and get paid on time by commercial health insurance plans, according to a new report from Crowe, a company that provides revenue cycle intelligence for providers. One of the report’s authors says that it’s difficult to parse what exactly is driving the trend, but she pointed out that Crowe’s data indicates many initially denied claims eventually get resolved — suggesting insurers are aiming to “hold on to the money a little bit longer.”

Commercial payers reimburse providers at higher rates than Medicare or Medicaid, which usually leads organizations to prefer a payer mix that skews more toward the privately insured, the Crowe report noted. Yet that comes with a downside: The firm found that compared to government payers, private insurers “take the longest to pay, require providers to jump through more administrative hoops to get paid,” such as prior authorization, and “delay payments to providers via claim denials at a higher frequency.”

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Leslie Small

Leslie Small

Leslie has been working in journalism since 2009 and reporting on the health care industry since 2014. She has covered the many ups and downs of the Affordable Care Act exchanges, the failed health insurer mega-mergers, and hundreds of other storylines spanning subjects such as Medicaid managed care, Medicare Advantage, employer-sponsored insurance, and prescription drug coverage. As the managing editor of Health Plan Weekly and Radar on Drug Benefits, she writes and edits for both publications while overseeing a small team of reporters who also focus on the managed care sector. Before joining AIS Health, she was a senior editor for the e-newsletter Fierce Health Payer, and she started her career as a copy editor at multiple local newspapers. She graduated with a dual degree in journalism and political science from Penn State University.

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