Avoidable Claims Denials and the Road to Payer/Provider Collaboration — ICYMI
Optum’s John Campbell discusses current challenges for state governments managing avoidable claim denials, the impact on Medicaid providers, and practical strategies for states to proactively improve the process.
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The estimated annual administrative cost of health care has eclipsed $1.1 trillion, according to a report from Optum. Recent studies peg nearly 25 percent of these costs as coming from clinical and administrative waste due to a lack of transparency between payers and providers which results in improper denials.
Medicaid in particular experiences a higher percentage of initial claims denials — 25 percent, as opposed to 7.3 percent for Medicare and 4.8 percent for commercial providers — and the percentage of provider revenue loss due to denials is also higher for Medicaid providers (17.4 percent) than Medicare (5 percent) or commercial providers (2.8 percent). There is a direct, causal link between claim denial rates and Medicaid provider enrollment.
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