Healthcare revenue cycle leaders across the country face a litany of challenges every day. From denials and downcoding to network status and the independent resolution dispute (IDR) process, providers are constantly working to recover the funds they are owed. Industry leaders recently shared their experiences dealing with a variety of topics around payor relationships.

Reducing Denials, Increasing Revenue

In the healthcare revenue cycle, denials are a part of hospitals getting paid by insurance companies. The key is finding ways to minimize those denials. Drew Mahome, Executive Director Revenue Cycle and Billing Operations at John Hopkins, found that having champions for different departments has helped minimize denials further upstream.

“Central coding, billing, they all have champions and they're responsible for understanding denials in their area,” said Mahome. “But I think more importantly, they're responsible for helping us come up with a solution to the denial and then really championing the change.”

By having these champions be subject matter experts in areas like oncology and laboratory, John Hopkins has been able to effect real change to their bottom line, attributing it to the collaboration and engagement they have among their champions.

“Last year, we reduced our final fatal denial rate by 12%, which was about a $20 million savings this year so far,” said Mahome. “It's only three months in the fiscal year, 30% improvement from fiscal year 24. So far, it’s been very impactful.”

For Erin Hodson, Vice President of Revenue Cycle at Inova Health System, fighting denials meant traveling upstream.

“We really went as upstream as we possibly could to [find the] root cause,” said Hodson. “I think that's something we're learning. We are hearing about many organizations that are root causing denials from every denial from the start, which I think is smart. We're looking at how we can do that further.”

Avoiding Downcoding

The use of Artificial Intelligence and third-party vendors by the insurance companies to automatically downcode claims is causing issues in hospitals’ healthcare revenue cycle. Even though the No Surprises Act includes a disclosure requirement for remits, sometimes they are there and sometimes not. Alla LaRoque, President of HaloMD said it is important to make sure they are included.

“If there's downcoding that's, you know, been administered on that specific claim, the payer is mandated to disclose the downcoded qualified payment amount, which is your medium contracted rate,” said LaRoque. “It's a methodology under No Surprises Act so you can actually see the difference. So, if you're able to scrub that data out on those remits, that will provide a significant amount of data on how vast this is or how big of a problem this is.”

Winning Through IDR

Another important area under the No Surprises Act hospitals need to utilize when it comes to out-of-network (OON) billing is the Independent Dispute Resolution (IDR) process. Consumer protections related to the No Surprises Act are generally recognized to include OON emergency services, OON nonemergency services provided during a visit to an in-network facility, and OON air ambulance services. The No Surprises Act generally limits the amount consumers pay for care in those situations, and specifies the methodology used to determine how much insurers must pay OON providers for care if the parties cannot agree on a payment amount. Under this methodology, either the insurer or the provider may initiate an IDR with a private arbitrator. Providers have found success with this process, but there could be more according to LaRoque.

“That is still incredibly underutilized simply because there's a lot of kind of misinformation there,” said LaRoque. “Some provider groups or hospitals simply don't have the scale, the staffing, the technology to be able to administer the process.”

In 2024 alone, more than 1.46 million federal IDR disputes were initiated, according to Congressional data analysis. Providers initiated over 99% of disputes and prevailed in about 85% of those disputes.

Source: Departments of Health and Human Services, Labor, and the Treasury, Table 1 in Federal IDR Supplemental Tables, https://www.cms.gov/nosurprises/policies-and-resources/reports ("2023 Reporting Year" and "2024 Reporting Year"). 2023 Q1 and Q2 data as of February 15, 2024; 2023 Q3 and Q4 data as of June 13, 2024. 2024 Q1 and Q2 data as of March 18, 2025; 2024 Q3 and Q4 data as of May 28, 2025.

“Providers are realizing significant revenue optimization from this, and I think for the first time in history of out-of-network reimbursement period, there's not a single payer who's deciding what is going to be fair and reasonable in terms of payment,” said LaRoque. “There is a legal mind, an arbitrator, who's completely non-conflicted, that looks at both offers and says, this is the reasonable offer, and that stands. So, the control has shifted.”

Conclusion

Successfully navigating the healthcare revenue cycle challenges providers face can be done. Key strategies include:

• Minimizing denials

• Finding ways to avoid downcoding

• Taking advantage of the IDR process

By focusing on these areas, healthcare organizations can face their challenges head-on and positively impact their bottom line.