Untangle the causes of medical necessity denials

Identify two key influences affecting your denial challenge

When analyzing their denial challenge, many providers focus on the overall denial rate and appeal success rate. However, these two metrics don’t give a complete or, in some cases, accurate picture of a hospital’s denial challenge.

These common denial metrics don’t account for two key influences on denials: self-denials and peer-to-peer appeals. Self-denials don’t appear on denial reporting and aren’t often tracked. Though often heavily underutilized, success at the peer-to-peer level avoids denials and isn’t reflected by denial and overturn rates.

Through this paper, Optum shows why hospitals cannot afford to neglect these two critical indicators of an organization’s denial challenge and how to account for them effectively.