Discreet ER Downgrades: A Growing Issue for Hospitals
Discreet Emergency Room (ER) downgrades are an increasingly pressing issue for hospital financial teams. Unlike traditional ER downgrades where the emergency room level on the remit is lower than the ER level on the claim, discreet downgrades present a unique challenge. In these downgrades, the ER levels on the claim and remit match, but the reimbursement is still based on the lower ER level negotiated rates and charges. This discrepancy results in lower reimbursements and necessitates more effort to recover revenue.
Identifying accounts affected by discreet downgrades is crucial. These accounts often have balance due values that match differences in ER level contract rates. Leveraging your analytics partner can help in identifying these opportunities and accounts.
Exploring Downgrades
While some hospitals are experiencing a surge in downgrades, others are seeing relatively flat volumes. However, this does not mean they are immune to the issue. Despite the overall flat trend, there are notable exceptions. Major payors are showing increasing rates of downgrades even in facilities with otherwise flat volumes. These increases are a cause for concern and underscore the need for vigilant monitoring and proactive management.
Even if you aren't seeing an overall increase, it's important to look beneath the surface at a payer level to identify potential bad actors with increasing rates.
For many hospitals, the volume of discreet downgrades is on the rise, with some experiencing as much as a 45% year-over-year increase. Key payers driving the increase in downgrades have shown significant acceleration in downgrade rates starting in Q2 of 2023. This period coincides with the timeframe when payers rolled out AI to deny claims in bulk. PMMC has created dynamic reports tailored to identifying downgrades, providing rapid and detailed insights on payer trends and strategies to identify and mitigate downgrades.
Conclusion: Proactive Management is Key
Hospital financial teams must stay vigilant in managing downgrades and other payment issues. Effective management is a multi-pronged approach. From a proactive standpoint, it’s important to ensure processes are in place that meet payer requirements, and that those processes are followed to prevent downgrades. For the inevitable downgrade that occurs, it’s paramount to have a robust analytical toolkit that identifies and alerts users of impacted accounts, so they can quickly be appealed. By staying informed and utilizing the tools and reports provided by our PMMC team, hospitals can better navigate the challenges posed by downgrades and secure their financial health.
To discuss how our PMMC insights can help your hospital manage ER downgrades more effectively, or to request your personalized downgrade report, please reach out to our team directly. Together, we can tackle these issues and ensure your hospital's financial stability.
