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Dawn Carey, Director of Denials and Appeals at Accuity, joins us to explore the evolving landscape of healthcare claim denials and the tactical responses needed to address them effectively. She reveals how AI, payer tactics, and clinical criteria manipulations are creating unprecedented challenges for healthcare facilities struggling to protect their rightful reimbursements.

• Post-COVID changes in denial patterns with auditors using AI to process unprecedented volumes of claims
• Distinguishing between AI-generated and human-reviewed denials is increasingly difficult
• Prepay denials force hospitals to adjust claims before payment, effectively holding revenue hostage
• Payers create their own clinical criteria for denials, often cherry-picking from established guidelines
• Hospitals must break down departmental silos between contracting, revenue cycle, and CDI teams
• Limiting the number of records payers can review through contracts is an effective mitigation strategy
• Regular meetings with payers, tracking strong cases, and leveraging peer-to-peer reviews help overturn denials
• Accuity's AI solutions include Amplify for chart review and new AI applications for denial management
• Interdepartmental collaboration is crucial for addressing increasingly sophisticated denial tactics
• Facilities using Accuity's integrated physician-coder model experience denial rates under 0.5 percent