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Denied insurance coverage claims are among the many largest challenges going through the U.S. well being care system—driving up prices and leaving suppliers with billions in unpaid payments.
Hilal Atasoy, an affiliate professor on the Rutgers Enterprise Faculty, thinks she’s uncovered a sublime if easy answer: higher software program administration. Her paper on the subject seems within the September concern of the journal MIS Quarterly.
Medical claims comprise a spread of knowledge, together with affected person demographics, medicines, medical histories and procedures carried out. Claims could be denied once they embody inaccurate info or uncovered providers, amongst different errors.
To strengthen the standard of well being information that medical doctors acquire, in 2009, U.S. lawmakers adopted the Well being Info Expertise for Financial and Scientific Well being Act, or HITECH, which incentivized the usage of digital well being report (EHR) programs. The objective—lauded on the time—was to make expertise the “foundation for health care reform.”
It was solely partially profitable. Whereas the transfer incentivized adoption, the ensuing mixture of programs from totally different distributors created interoperability challenges that may contribute to say denials, Atasoy stated. When software program utilized by one clinic or hospital system differs from one other, affected person information can get jumbled or go lacking—making denials extra doubtless.
Between 2000 and 2020, some $745 billion price of care was supplied with out compensation, and declare denials have been a major contributor. Atasoy wished to grasp the potential function that EHR applied sciences performed in these well being payer rejections.
To quantify the connection between unpaid payments and gaps in software program interoperability, Atasoy and colleagues from Temple College and the College of Wisconsin-Madison analyzed the well being data of greater than 19 million anonymized affected person visits to 48 Maryland hospitals. The dataset included info on whether or not preliminary claims have been accredited or rejected.
By evaluating this information with info on EHR adoption and software program sourcing, the researchers decided that software program choices play an outsized function in whether or not claims are initially accredited or denied. The dataset didn’t seize appeals or eventual resubmissions.
As an illustration, they discovered that when hospitals relied on a number of distributors fairly than a single vendor, declare denials rose. Against this, hospitals that standardized software program from a single vendor noticed denials lower to 1.03% from 1.18%—a seemingly small shift that interprets into vital financial savings throughout hundreds of thousands of claims.
The researchers additionally investigated whether or not physicians’ familiarity with EHR functions from totally different distributors may clarify declare denials. They discovered that when physicians practiced throughout hospitals with related EHR programs, declare denials decreased, since familiarity improved information accuracy and compliance.
“Our findings suggest that [EHR] alignment improves clinical data collection and adherence to payer requirements, ultimately reducing claim denials,” they wrote.
Lowering the price of well being care within the U.S. would require a basket of options; expertise is barely a part of the reply. And but, because the researchers discovered, EHR coordination has the potential to scale back pointless spending, and in flip, convey prices again right down to Earth.
“If there is any inefficiency in this process, that can lead to surprise bills for clinics and health care organizations, which in turn shifts the cost burden to patients and eventually, to taxpayers,” stated Atasoy. “Reducing denials is among the best ways to help contain skyrocketing health care costs.”
The findings counsel that the federal authorities ought to work to strengthen EHR certification and decrease variation amongst distributors, Atasoy added.
“Placing greater emphasis on the usability and standardization of user interfaces and layouts will improve the accuracy of information flow across disparate applications, suggesting a potential to reduce the extent of errors in claim processing,” the researchers wrote.
Extra info:
Sezgin Ayabakan et al, The Interaction Between Healthcare Info Applied sciences and Denied Claims, MIS Quarterly (2025). DOI: 10.25300/misq/2024/17469
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How higher software program selections may minimize US well being care prices (2025, October 3)
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