By Charlie Eckert, Vice President for Strategic Growth, Libman Education

Having worked in the HIM/Revenue Cycle area for nearly my entire career, I am very aware of the constant push-pull between payers and providers. At the moment, the winds are with the payers.

If it is your sense that payers have become increasingly aggressive with denials, you are not alone. Libman Education’s 2024 HIM Professional Census (view the complete Report of Findings HERE) inquired about payer denials and the impact of these denials on healthcare organizations. Nearly 80% of respondents report an increase in claim denials in the last year; 55% of all respondents specifically report increased denials due to clinical validation while 23% report an increase due to coding errors.

One of the best tools for ensuring your organization is reimbursed appropriately for services provided is through the quality of your coding. Coding that is accurate, by-the-book, and complete, is also by definition defensible. Payers may still reject your claim, but your organization is in a much better position to push back and demand what you are owed.

The second tool in your arsenal is your program of internal audits. Finding your own coding errors before the payer does gives your organization the chance to correct any claims that have already been submitted and conduct internal training of coding staff to forestall additional errors in the future.

Another anecdotal finding of the 2024 HIM Professional Census was that there are not enough internal auditors and the result is fewer audits, less in-depth audits, and less pro-active audits. Healthcare organizations without a robust program of internal audit are flying blind into the wind.

It takes a special kind of person to be an effective internal auditor. They need excellent clinical understanding and in-depth command of the coding systems. They need to understand their organization and be able to work effectively with the entire revenue cycle team as well as clinicians. They need to be able to communicate complex information in a way that is supportive of the team while resulting in the needed change.

We suggest looking to your best coders for the internal auditing staff you need. As AI and other technologies expand in support of the coding function, your coders are increasingly freed from routine production and can focus on applying their knowledge in new ways to support the organization. For the right person, internal auditing offers an opportunity to contribute meaningfully to your organization’s success.

Just like your coders, payer auditors have quotas and productivity goals to meet. They are challenged to keep up with changes in codes and guidelines. Their challenge can become your advantage.

Time for the winds to shift.

Link to original article: https://libmaneducation.com/payer-denials-time-for-the-winds-to-shift/?utm_source=Whats+What+Wednesday&utm_medium=email&utm_campaign=LEI2025&utm_content=LE-WWW-Denials-Eckert-WED-5-7-25-11am