Automation Denial Improvements – Top 15 U.S. Health System

Date

Tue, Apr 8, 2025, 05:00 AM

Automation Denial Improvements – Top 15 U.S. Health System

September 2024

2023 Denial Performance – At-a-Glance

$21.2 Million Avg. Write-Offs/Month (2023)

One of the primary goals leading into 2024 was related to reducing denial write-off dollars through operational enhancements and denial prevention.


15.1% NPR	Initial Denials: The average initial denial dollars per month as a % of Net Patient Revenue (NPR)
2.1% NPR	Denial Write-Offs: The average denial write-off dollars per month as a % of NPR
16.9%	Primary Denial Rate: The percentage of claims with a denial as a % of all claims paid in July of 2023
73.7%	Recovery Rate: The average recovery rate per month
$25.7M	Net Revenue Impact from Denied Claims: The average net revenue impact
$59.3M	Cash Collections: The average recovery amount per month

2024 Denial Performance

2023-2024 Comparison

$26.5 Million

YOY Cash Collections Increase

Represents the increase in cash collections per month.

2023	2024	Variance	Metric
15.1% NPR	14.1% NPE	-1.0%	Initial Denials
2.1% NPR	0.9% NPR	-1.2%	Denial Write-Offs
16.9%	13.4%	-3.5%	Primary Denial Rate
73.7%	87.9%	+14.2%	Recovery Rate
$25.6M	$22.8M	-$2.8M	Net Revenue Impact from Denied Claims
$59.3M	$90.2M	+30.9M	Cash Collections

All figures represent monthly averages from Q1-Q2 2023 and Q1-Q2 2024 with the exception of Primary Denial Rate. Primary Denial Rate compares July 2023 to June 2024

Denial Performance Priorities

01 Top Quartile: Primary Denial Rate

End the year inside the top quartile for Primary Denial Rate compared to our Epic peer group.

02 Decrease Cost 2 Collect

Increase Net Collections through improved performance, while evaluating opportunities to reduce expenses.

03 Increase Automation Utilization

Take advantage of the automation opportunities provided by Epic, while filling the gaps utilizing internal/external automation.

04 Improve Payer Engagement

Leveraging internal and external payer relations to improve payer engagement and performance.

Operational Enhancements – Automation

135+ Thousand - Accounts Worked via Automation

The projected number of accounts that will be worked through automation in 2024, allowing our subject-matter experts to focus more on appeal submission and complex denial resolution

Process	Payer(s)	Summary
Denial Statusing	Cigna, UHC, Oscar	The BOT is going to the payer portal and providing the most recent status on the claim following an appeal.
Itemized Bill Submission	Cigna, Oscar, BCBS, Wellcare, Aetna	The BOT is uploading the itemized bill to the payer portal following a denial for Additional Information.
Denial Appeal Submission	Cigna	The BOT is submitting appeals for no auth denials on OP accounts with a blank auth field.
Non-Par Exchange Underpayments	Cigna Connect	Utilizes automation to resolve Non-Par Exchange accounts with an allowance equal to or exceeding.
Non-Covered Lab Denials	BCBS	Automatically identifies accounts meeting criteria: full denial from specific BCBS plans, Outreach Account Class and processes NRP for noncovered amount.
CDS Clinical Release of Information	All	Accesses accounts in Clinical Denial WQs, request an ROI on these accounts and upload the medical records to the designated folder for staff to complete.

SOURCE: Apprio

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Automation Denial Improvements – Top 15 U.S. Health System