Implications of managed care denials for pediatric inpatient care.
With the growing penetration of managed care into the healthcare market, providers continue to experience increasing cost constraints. In this environment, it is important to track reimbursement denials and understand the managed care organization's rationale for refusal of payment. This is especially critical for providers of pediatric care, as children justifiably have unique healthcare needs and utilization patterns. We developed a system for tracking and documenting denials in our institution and found that health maintenance organizations denied claims primarily for one of three reasons: medically unnecessary care, care provided as a response to social (rather than medical) need, and provider inefficiencies. Health maintenance organization denials are also growing annually at our institutions. This knowledge can not only help providers of pediatric care more effectively negotiate future contracts, but provides an opportunity to differentiate the health needs of the pediatric patient from those of the adult. This information can be used as a basis for education, pediatric outcome studies, and guideline development--all tools that can help providers receive reasonable reimbursement for pediatric services and enable them to meet the complex health needs of children. Recommendations for action are discussed.
Kini
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Children's Hospital of Wisconsin, Milwaukee 53201, USA.
Timberlake
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R
D002648:Child; D002908:Chronic Disease / Q000191:economics; D006279:Health Maintenance Organizations / Q000191:economics*; D006776:Hospitals, Pediatric / Q000191:economics* / Q000706:statistics & numerical data; D006801:Humans; D007345:Insurance Claim Review / Q000706:statistics & numerical data*; D017063:Outcome Assessment, Health Care; D010343:Patient Admission / Q000191:economics*; D012017:Referral and Consultation; D017664:Uncompensated Care / Q000706:statistics & numerical data; D019564:Unnecessary Procedures / Q000191:economics; D014922:Wisconsin