Strategic auditing and financial sustainability in supplementary health: a multi-criteria and technological roadmap for reducing claims denials

Resumo

The financial sustainability of healthcare providers is a growing global concern. Operational inefficiencies in the revenue cycle intensify this challenge. In mixed health systems like Brazil's, providers in the supplementary health sector are under significant pressure. This pressure stems from mounting costs and intricate reimbursement processes. Claim denials from health insurers are a critical source of revenue leakage and pose a major threat to the solvency of hospitals and clinics.

To develop a comprehensive strategic framework that addresses claims denials and enhances the financial sustainability of healthcare providers. The proposed integrated model combines strategic auditing, multi-criteria decision analysis (MCDA—a method of decision-making based on multiple factors), and emerging technologies such as artificial intelligence (AI—computer systems that perform complex tasks). A systematic literature review was conducted to gather evidence on claims denial management, healthcare financial sustainability, and the use of MCDA and AI in health services.

The review revealed a fundamental 'volume versus value paradox' in claims denials. Subsequently, the COSTCARES (Claims Optimization through Strategic Technology, Criteria-based Analysis, and Revenue Enhancement Strategies) framework was developed. The COSTCARES uses the Flexible and Interactive Tradeoff (FITradeoff) MCDA method. This method helps construct a strategic decision matrix that prioritizes denial management efforts. Finally, the review proposes a technology-enabled 'Sustainability Roadmap'  to support a robust revenue cycle.

The literature review confirms that claim denials are a major financial drain. Often, these denials are mismanaged. The analysis revealed a key distinction: high-volume, low-value administrative denials and low-volume, high-value technical denials. The FITradeoff decision matrix provides a framework for allocating resources. It recommends using automation and AI to handle administrative denials. For technical denials, it suggests specialized clinical audits and education. The resulting Sustainability Roadmap offers an AI-driven, four-step process. This process covers  everything from patient admission to final reimbursement and aims to proactively prevent denials.

Transitioning from reactive, fragmented denial management is essential for healthcare providers. The COSTCARES framework and Sustainability Roadmap provide an integrated approach to improving revenue cycle management. Strategic denial management can reduce revenue leakage, boost operational efficiency, and ensure long-term financial sustainability.