How Intermountain Health Overcame Healthcare Payer Challenges with Robust Data and Analytics

Editor’s note: This article is based on a 2024 Healthcare Analytics Summit (HAS) session titled, “From Nay to Yay - Denials to Dollars,” presented by Kearstin Jorgenson, MSM, CPC, COS, Operations Director for Physician Advisor Services, and Sathya Vijayakumar, MS, MBA, Senior Clinical Operations Manager with Clinical Excellence, both with Intermountain Health.

Healthcare payers' rejection of insurance claims can severely impact patients, providers, and healthcare institutions' revenue cycle management. Denied claims may interrupt the flow of care and postpone essential medical services.

Additionally, these denials can lead to higher costs and efforts in resolving claim disputes. As such, health systems are increasingly focusing on reducing claim denials as a critical priority.

Intermountain Health identified novel opportunities to collaborate with one of its most prominent healthcare payers to improve the patient experience while reducing insurance claim denials.

In its targeted approach to fortifying payer relationships, Intermountain adopted innovative technology and healthcare analytics into a new review process that eliminated manual spreadsheet tracking and improved cross-functional team collaboration. This resulted in Intermountain reviewing more than two thousand cases and overturning more than $20M in denials over 24 months.

Intermountain shared its journey with industry leaders at the Healthcare Analytics Summit 2024 (HAS 24), addressing three main objectives:

1. Collaborating with payer contracting to involve payers in constructive peer-to-peer conversations.
2. Forming a diverse multi-functional team of stakeholders to manage the claims processes.
3. Streamlining the claim denials process by implementing a cloud-based, automated data monitoring tool.

Engaging Healthcare Payers in Productive Peer-to-Peer Conversations

Effective partnerships with healthcare payers should prioritize meaningful discussions to address the issue of rising payer denials, which can lead to significant financial losses for healthcare systems.

During the HAS 24 educational breakout session, Intermountain’s Kearstin Jorgenson, MSM, CPC, COC, CIC, CCS Senior Operations Director for Physician Advisor Services, and Sathya Vijayakumar, MS, MBA, Director – Physician Advisor Services with Clinical Excellence, showcased how they successfully implemented a peer-to-peer review process and claims denial tracking tool that resulted in over $35 million in projected revenue. 

By establishing open communication among care management, physicians, healthcare payer representatives, revenue integrity, and cross-functional teams, the health system gained valuable insights to improve outcomes. 

Furthermore, utilizing healthcare analytics enhanced coordination and enabled efficiency by providing real-time payment tracking of case progress and outcomes, and the ability to cull necessary documentation in a centralized platform. This streamlined approach facilitated improved communication and enriched meetings with healthcare payers.

Establishing a Multi-Functional and Diverse Claims Management Team

Intermountain initiated its initiative to reduce denials by bringing together a diverse set of stakeholders, including payers, physician advisors, care management teams, and revenue integrity and billing staff, too. At the time, the group did not adequately track how much revenue the health system lost or delayed due to denials, nor were claims denial trends easily accessible.

Engaging essential stakeholders in the denials review process, however, proved to deliver the following benefits:

• Improved data capture processes.
• Ensured proper documentation capture.
• Centralized and optimized its patient population care needs.

As an example, Intermountain developed diagnostic criteria for treating certain medical conditions, such as sepsis, which one of its payers agreed to honor. This agreement guaranteed payment for claims once the criteria were met. By implementing these criteria for sepsis, Intermountain successfully eliminated denials related to sepsis with that particular payer and saved over $5M in the process.

Automating the Peer-to-Peer Request Process Through Web-based Data Tracking

Jorgenson and Vijayakumar encouraged providers to enhance their algorithms and embrace modern technology to align their data capabilities with payers and effectively manage the intricate and data-heavy claims transmission process. Intermountain discovered that by implementing a robust, semi-automated peer-to-peer process, they could scale their denials work across multiple payers without needing to increase full-time employees. 

Their approach involved tracking cases in real-time using a newly developed software tool that replaced spreadsheets and streamlined claims management processes. The tool templates included pre-established clinical criteria and citations for specific conditions, allowing Intermountain to broaden its claims denial program. 

All stakeholders can access this tool, which provides comprehensive patient case information and triggers alerts for necessary actions. Additionally, a new written appeals process complements the peer-to-peer system, with the latest tool monitoring the denial workflow. 

Initially handling around 50 denial reviews per month, Intermountain now manages >200 monthly and is working towards implementing the web-based tool system-wide.

Key Revenue Cycle Management Challenges Related to Billing, Payments

Intermountain’s example demonstrates the importance of integrating healthcare analytics with insurance claims management workflows so that providers can secure timely approvals. Yet, the healthcare industry often faces key challenges in utilizing healthcare analytics, including data quality, integrity, and integration across its information technology ecosystem. 

Alongside these broader analytical shortcomings, the speakers also expressed that managing insurance claims presents specific hurdles that healthcare organizations must address, such as the following: 

• Overreliance on spreadsheets for claims data management,
• Lack of solid relationships between clinicians, teams, and payers,
• Inadequate technology systems for claims denial management,
• Absence of cohesive strategy integrating analytics and processes, including EMR claims workflows,
• Poor documentation leading to lost revenue,
• Difficulties with provider-payer communication to resolve claims and documentation discrepancies,
• Limited monitoring of encounters and payer criteria specifications,
• Gaps in closing the approval-to-payment loop efficiently, and
• Keeping up with payer technology advancements in claims management.

Fostering Teamwork and Transparency to Boost Healthcare Payer Partnerships, Financial Performance

As demonstrated by Intermountain, effective management of healthcare payer denials necessitates the utilization of advanced healthcare analytics and cutting-edge technology to seamlessly integrate, notify, and expedite claims data.

By streamlining operations through automation, Intermountain saved valuable time and resources and enhanced its financial performance while empowering healthcare teams and external partners to address critical needs efficiently.

Additional Reading

Interested in learning more about this topic? We suggest the following articles:

How One Hospital System Advances Clinical Documentation Improvements with Augmented Intelligence

Analytics Relieves Payer Authorization Pains

Denials Management Analytics Reduces Denials by Nearly $5M

Integrated Data Platform and Improvement Efforts Recovers $3M in Revenue