Teaching Hospital Reduces Medical Necessity Denials

This case study details the efforts of Saint Peter’s University Hospital in New Jersey to address the significant increase in medical necessity denials. The hospital's leadership recognized the need to identify the root causes of these denials to develop a proactive prevention strategy. Collaborating with Chartis, the hospital assessed its revenue cycle and implemented a comprehensive strategy that included establishing collaboration across utilization management, case management, and revenue cycle functions. Key initiatives included the creation of a new clinical denials dashboard for data-driven decision-making and real-time patient status review meetings. As a result of these efforts, the hospital achieved a dramatic decrease in denials, increasing inpatient revenue by $17 million within nine months. The implementation of clear roles and responsibilities, along with a dedicated physician advisor model, contributed to improved peer-to-peer reviews and a roadmap for continuous improvement in denial management.