New report: Surging claims denials are undermining working relationships between health systems and health plans

CHICAGO (Nov. 14, 2024) — Relationships between health systems and health plans have worsened over the past three years, according to a new report from the Healthcare Financial Management Association (HFMA)’s award-winning editorial team. Nearly six out of 10 chief financial officers (CFOs) surveyed for “Bridging the Payer-Provider Divide” characterized the changes in payer-provider dynamics as negative, with 80% of those blaming health plans for “intentional or systematic efforts to increase denials.”

Survey respondents described high rates of payer denials and claim adjudication errors as “dirty tactics,” “brazen” and “shocking.” Surging denials have led 75% of respondents to add financial services staff in the past three years to manage the process.

In contrast, health plan executives interviewed for the report maintain the state of payer-provider relations is strong, pointing to value-based care initiatives as evidence.

“Hospitals and health plans engaged in value-based payment initiatives have had some success in developing collaborative working relationships,” said HFMA Senior Vice President for Content and Professional Practice Richard L. Gundling. “But on the fee-for-service side, the tenor of these relationships has deteriorated as providers’ frustration levels with payers’ administrative requirements and expectations have increased.”

Most survey respondents are not looking to technology as the tool that will put an end to delays and unnecessary denials. About 64% of CFOs surveyed believe it’s too early to tell what impact artificial intelligence will have on their relationships with payers. An additional 29% expect AI to make matters worse. Increased payer transparency around payment rules and behaviors was cited by three quarters of respondents as the primary change that could strengthen their organization’s payer relationships.

Ultimately, strained relationships impact consumer satisfaction—often with their healthcare providers. About 87% of CFOs surveyed said the current state of working relationships with health plans impacts their organization’s ability to provide optimal care to patients.

The report concludes with strategies for building stronger payer-provider connections.

About HFMA

The Healthcare Financial Management Association (HFMA) equips its more than 126,000 members to navigate a complex healthcare landscape. Finance professionals in the full range of work settings, including hospitals, health systems, physician practices and health plans, trust HFMA to provide guidance and tools to help them lead their organizations, and the industry, forward. HFMA is a not-for-profit, nonpartisan organization that advances healthcare by collaborating with other key stakeholders to address industry challenges and providing guidance, education, practical tools and solutions, and thought leadership. We lead the financial management of healthcare.

Press inquiries should be directed to:

Brad Dennison
Healthcare Financial Management Association
(630) 386-2945
[email protected]