During an executive roundtable at the 8th Annual Becker’s Health IT + Digital Health + RCM Meeting, Aspirion leaders Jeff Podraza and Nancy Momcilovic discussed denial prevention, focusing on the importance of managed care contracts and agreements in relation to state and federal law and payer policy.
The speakers emphasized the need for health systems to have a clear understanding of their managed care landscape and to optimize their agreements. They noted that denials have increased since 2020 and stressed the importance of having clear and realistic exceptions in contracts.
Momcilovic highlighted the importance of collaboration across departments during contract negotiations to ensure all costs are covered. She also pointed out the imbalance in many managed care agreements, which often benefit the payer more than the provider, suggesting that providers should renegotiate for more balanced agreements.
Podraza discussed the importance of stipulating clinical review criteria in managed care agreements to ensure consistency in determining medical necessity. This practice is becoming more common and can help prevent denials.
Both speakers advocated for provider appeal rights and the use of Independent Review Organizations (IROs) in managed care agreements. Momcilovic noted that the presence of IROs can lead to fewer denials at the second level of appeals, as carriers are aware of this additional oversight.
Read full Becker’s Hospital Review article.