I recently had a conversation with a healthcare research expert to talk about some of the insurance company shenanigans I see via my work at Anomaly. After about 3 minutes they made a comment like "WTF...this sounds like the Dark Web of healthcare?!".
And this is from someone who really knows healthcare. It made me think that it would be fun to start sharing some of these learnings more broadly with my network, because I've been doing this stuff a long time now and I still learn something new every day.
I'll start with a seemingly benign topic...like "I saw a headline that insurance companies have 24% denial rates, is this true???".
Well, kinda sorta maybe 😊
In healthcare even something as simple as denial rate is complicated. At a high level, there are literally dozens of different ways to calculate denial rate, not including the endless amount of nuanced inclusion/exclusion criteria that can drastically influence the final numbers (which I'll discuss in a separate post).
Are you talking about initial denial rate or final denial rate? Are you counting multiple denials for the same encounter or not? Are you talking volume vs dollars? And with volume do you mean line level or claim level? With dollars are you talking gross or net? What timeframe are you using? Service date or remit date? Any combination of the above could be used to describe denial rate...and each one of those can be valid, but it really depends on the use case. For example, using remit date can be helpful operationally so you can see changes in more real-time while service date can give you a better view into actual performance over time.
In my next post I'll dive into "Wait...what the hell is a denial actually?" where we will talk about Group Codes, RARCs, CARCs and the nuance of trying to lock in a standard definition of a denial (and how the combination of methodologies and nuances in definition can be manipulated for clickbait and misinformation).
Anyone else like nerding out on denial rate??? Would love to hear if this type of info is useful and any other topics/specific items you'd be interested in hearing about. And even if it isn't useful, I'll probably keep blabbing about it anyway 😂
