Challenging commercial payer line item charge denials

Editor’s note: Valerie A. Rinkle, MPA, CHRI, will present “Defense Strategies for Commercial Payer Line Item Charge Denials” with Glenn Solomon, JD, on day one of the 2023 Revenue Integrity Symposium, which will take place on September 18-19 in Charlotte, North Carolina. Rinkle is president of Valorize Consulting and has more than 35 years’ experience in healthcare policy, finance, strategy, and revenue management operations. Rinkle serves on the NAHRI Advisory Board.

Q: In what ways does your session challenge revenue integrity professionals to think outside the box?

Rinkle: I like to say that relationships are as important as resources when it comes to revenue integrity. Advocating with managed care and leadership to bring the significant issue of line item denials to arbitration with the payer is a topic that requires communication, stakeholder engagement, analysis, and authoritative sources. It is, in many ways, an ultimate challenge.

Q: What’s the biggest challenge in revenue integrity right now? How does your session help tackle this?

Rinkle: The biggest challenge is to constantly prioritize what work will have the most benefit, either financially or for compliance. This session is about helping the organization be paid what they fairly negotiated with a payer for the good clinical care they are giving to patients, as well as not letting payers misuse their position, power, or CMS citations to unilaterally underpay.

Q: What’s one of the key pieces of information you would like people to take away from your session?

Rinkle: Challenging the payers is worth it not only to get the payment due the hospital, but to stop the behavior. The more hospitals that challenge the payers, the more payers will stop this behavior. Payers are increasing this behavior because they have not been challenged.

Q: What are you most excited about for this year’s topic? Or, what are you most excited about for this year’s conference?

Rinkle: I am most excited to connect with my friends and colleagues and ensure that NAHRI can assist our members with what is top of mind for them!

Q: What's a great piece of advice you've received regarding revenue integrity? Or, what advice do you like to give people about revenue integrity? 

Rinkle: Get out there in the departments. Shadow people in their work and become revenue department managers’ right-hand resource to help them be more successful in their roles. Don’t merely focus on work queues, edits, or chargemaster changes—build those relationships!