Q&A: Monitoring denial volumes

Q: Are you seeing an increase in denials at your organization?

Ashley Brown, CHRI, RH-RCMS, RH-CBS, CAH-CBS, CH-CBS, CH-RCMS, revenue cycle analyst at La Paz Regional
Hospital in Parker, Arizona: We have seen an increase with the downcoding of the levels. Our two biggest culprits of that, however, [on the commercial side] have been Humana and Cigna. We’ve submitted a lot of appeals and overturned some of those denials, but there’s definitely been a large increase in that particular area.

Kelli L. Howard, MS, CSPPM, senior manager of revenue integrity at Mayo Clinic in Phoenix, Arizona: We’re seeing a lot of the same trends that others are seeing: a lot more of the initial denials but appeals are often successful. Medical necessity in the outpatient space is always a tricky one with our commercial contract payers and more difficult to mitigate.

Jaclyn Woolnough, director of revenue integrity at MetroHealth in Cleveland, Ohio: Where we’re seeing a lot of that is really in two areas. One is within our emergency department (ED) setting, where payers are adopting their own policy as to what constitutes an ED level of service. They are, in some cases, downcoding those ED levels of service and other cases they are flat out denying, saying that it doesn’t meet their policy. This is actually becoming a bigger issue with some of our commercial payers as we speak. Another area that we have seen a pretty significant increase is in lab services. Different payers again adopt different medical necessity policies around when a lab is justified versus when it is not, and trying to manage which payers will accept which labs under which circumstances is one of our bigger focuses right now.

Editor's note: Learn more about how revenue integrity programs are tackling denials in NAHRI's 2026 State of the Revenue Integrity Industry Report.