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Many providers believe that they are being paid correctly until a situation develops such as a reduction in cash flow due to a number of claim denials. We have recently seen medical necessity denials become more prevalent in the marketplace. Don't let reality slap you in the face. Confront your problems by asking for assistance. Some of the best hospitals and largest medical practices in the country have faced the same issues you have encountered. Knowing that, they have consulted specialists that have stabilized their business and set them on to the road to recovery.

Payment denials are best combated through knowledge and, as we all know, knowledge is power. We have helped clients both large and small through the following activities:

• Educating your patient billing, scheduling and collection staff on all relevant laws and regulations regarding payment for healthcare services. A key outcome from educational efforts is staff empowerment to take on insurers’ denials by knowing their "payment rights."
• Digesting contracts into understandable terms to ensure that your staff is knowledgeable in all of the provisions of your payer contracts. Many administrative and/or medical denials can be nipped in the bud through strict compliance with payer protocols.
• Teaching staff how to enforce payer compliance by developing follow up tools that will track key patient and insurer data elements, correspondence, and other communications. Accuracy of records will assist your staff in leveraging their newly found knowledge of "payment rights."
• Developing strong contracting philosophy for you business and supplying you with guidelines and tools to extract the best concessions from payers. Many providers have found that once their contracts have been "straightened out", denials become less of an issue for them.

Another way to increase the effectiveness of your denial strategy is to make full use of the State law pertaining to Independent Utilization Review Organizations (IURO) oversight of managed care plan denials. The Health Care Quality Act that was enacted in 1997 gave New Jersey residents many important consumer rights. One of the most important was the right to appeal denials to an independent organization for binding arbitration when an HMO or other managed care plan denies, limits or terminates a covered service on the grounds that it is not medically necessary. Providers, with the approval of the insured, have expedited the process by assisting consumers with providing the necessary documentation to the IURO. Below you will find an excerpt from the Department of Senior Services data on the percentages of overturned/affirmed claims denials since inception of the program in 1997 by payor:

	IURO	IURO
HMO Product	For Patient	For Plan
Aetna/USHC	49%	51%
Amerihealth	46%	54%
Oxford	46%	54%
HealthNet	45%	55%
HMO Blue (HHNJ)	45%	55%
Non-HMO Product
Aetna/USHC	75%	25%
Amerihealth	60%	40%
CIGNA	60%	40%
HMO Blue (HHNJ)	50%	50%
HealthNet	43%	57%

Combining process enhancements with the use of regulatory remedies can yield great results for your organization. Although the process is complex, we have helped many beleaguered healthcare providers implement solutions that make sense. Remember - admitting you have a problem and seeking help is the best path towards fiscal health!