.png)
Behind every denied claim is care that was delivered, documented, and still questioned by payers. It’s a frustrating fact that seems like it should be solvable, yet remains a struggle for most health systems. We wanted to know why, to get into the messy reality of what’s actually preventing progress. And, because we have a wealth of expert knowledge at SmarterDx, it was easy to tap into the perspectives of clinicians who have spent time on the ground addressing the very issues that impact the industry today. Here’s what our UM experts had to say about how we got here — and where we can go next.
SmarterDx key perspective: Surviving in UM means doing more than humanly possible just to get by. Clinicians make high-stakes status determinations across dozens of complex cases each day, creating significant risk for inconsistency and missed opportunities. Health systems need technology that surfaces clinical evidence and medical necessity alignment earlier to help reduce the burden of manual chart review.
Debi Halverson, RN:“The workload is just unsustainable. A single UM nurse reviews 25–30 charts a day — and each review takes up to an hour. There are only 24 hours in a day…that math doesn’t add up. To manage, you end up rushing reviews, missing important details, and sometimes mis-statusing patients.”
Ruben Amarasingham, MD:“Utilization management has historically been a siloed process where health systems have had to allocate dedicated staff to review patients as they’re coming into the hospital and decide: Do they qualify for inpatient status? Do they qualify for continuing to be in the hospital? That takes a lot of clinical resources.”
Fawaz Habeeb, MD, CMPC, CCDS:“A person has finite cognitive capacity and mental bandwidth, and UR work is exhausting and fatiguing. On top of that, regulatory changes and aggressive payer practices all work together to create a situation where it’s quite challenging to carry out work in a consistent, high-quality way, every day.”
Jeannine Raymond MS, RN:“Dedicated UM teams are common in larger health systems, but less so in smaller and community hospitals. There, case managers frequently absorb UM responsibilities in addition to their existing duties, creating operational and staffing pressures.”
SmarterDx key perspective: AI is transforming healthcare, especially for payers that automatically identify documentation gaps to immediately deny claims. Health systems need tools that surface level-of-care recommendations so that medical necessity is clear before a denial can occur.
Debi Halverson:“Everybody is afraid of denials, but insurance companies deny anything that they can. Denial rates are going up not because the hospitals aren't doing well or they aren't doing the right thing…it’s that insurance companies are of the mindset that if they deny, your facility might not have a utilization management department or a denial department and so you won't fight that denial.”
Fawaz Habeeb:“Payers will say denials are legitimate due to lack of documentation and lack of actual medical necessity. Essentially, they’ll say that bits of crucial information are missing and then deny the claim — but that’s not technically true.
For example, let’s say a patient is in hospital and the doctor is managing their abdominal pain and vomiting. That patient’s diabetic gastroparesis is the underlying cause of the symptoms. Every time the physician writes a progress note, it’s to document the current status of the symptoms — what the clinical team needs to know. They don’t always write that the vomiting and pain are due to diabetic gastroparesis, because that’s a given. But not saying that every time you document, which is very common, leads to denials and flags for lack of medical necessity.”
SmarterDx key perspective: The goal of clinical documentation has evolved far beyond its original purpose of facilitating communication between clinicians. To satisfy the requirements of payers and regulatory agencies, health systems need technology that breaks down silos and enables faster, more accurate utilization and coverage decisions, reducing administrative burden.
Fawaz Habeeb:“Historically, clinical documentation was meant to be a form of communication between clinicians. You didn't have all these other stakeholders — quality reporting agencies, payers, regulatory agencies, CMS and so on and so forth that were scrutinizing it. Physicians and nurses are not trained to document with this level of stringency. They’re trained to document in order to communicate with other clinicians, not to defend claims to payers.”
Naseem Amara, MD:“Now, it’s basically just an arms race. Providers have to get more and more ammo to prove their case and then payers go get more and more ammo to deny those cases.”
Ruben Amarasingham:“You could write your note one way and it makes the determination for utilization management take five seconds, or you could write it another way and it makes the determination take an hour — and you’re still probably going to get it wrong.”
SmarterDx key perspective: Clinicians need to focus on patient care, not tracking denials, managing appeals, or navigating payer processes. For health systems, this starts to become impossible without help from solutions that surface supporting clinical evidence at the point of care — which can prevent denials before they occur.
Debi Halverson:“With a lot of small community hospitals there will be one nurse that’s doing so much. Oftentimes, the denials weren’t even sent to them. And with most denials, you have to address them within a certain amount of time. You also have to do a peer-to-peer review within a specific time frame.
If the denial isn’t sent to your facility, you can't fight it. If you don’t have physician to review it, you can’t do peer-to-peer review. So then at these health systems, they just would downgrade everybody once they got a denial. They would just downgrade it automatically in order to get a payment.”
Naseem Amara:“The priority in the ER is stabilizing the patient — not proving to the payer that the patient is sick. Providers understand that they're going to write notes and document care, but the first priority is to actually get stuff done and take care of the patient and keep them safe.
So they tend to see the payer as sort of the enemy and someone that's blocking them taking good care of their patients. Of course there are always cases of overuse, and waste or fraud, but the majority of time, physicians are really trying to just take care of the patient and they feel that the payer's coming in and blocking them.”
SmarterDx key perspective: The value of UM teams can’t be understated. They need to be able to focus their attention where it adds value instead of wasting clinical resources reviewing cases where determinations are clear. AI can help health systems work strategically through reviews so teams work smarter, not harder.
Jeannine Raymond:“In a perfect world, you’d have a strategic, targeted approach to UM where you’re not reviewing 100% of cases — because not all cases need review. Instead, you’d have a system that helps you identify and focus on the cases that matter most.”
Naseem Amara:“Payers and health systems are both spending inordinate amounts of money and resources — a huge portion of our health care budget goes to this arms race. But there are tons of areas of very clear medical necessity agreement. And if there was just a more cohesive effort to find these areas of agreement, such as identifying certain codes that don’t warrant prior authorizations or certain scenarios that can be auto-approved, rather than pitting everybody against each other, everybody would spend less money and it would be a win-win all around.”
Debi Halverson:“If we could have a smooth UM workflow that lets us know which patients need review — that would be great. There are certain cases we just don’t need to review. A patient who is intubated? They are going to be inpatient. Someone with appendicitis? Maybe they need a review, but it should be quick, they’re probably outpatient. So “better” in UM would be making that type of workflow happen.”
Ruben Amarasingham:“Where possible these determinations should be handled at the point of care so that a lot of downstream processes are unnecessary. That will reduce the need to have that separate silo. Later, if you had systems that enabled you to achieve 100% review because you're assisted by AI systems, major reimbursement gaps could be closed.”
Behind every denied claim is care that was delivered, documented, and still questioned by payers. It’s a frustrating fact that seems like it should be solvable, yet remains a struggle for most health systems. We wanted to know why, to get into the messy reality of what’s actually preventing progress. And, because we have a wealth of expert knowledge at SmarterDx, it was easy to tap into the perspectives of clinicians who have spent time on the ground addressing the very issues that impact the industry today. Here’s what our UM experts had to say about how we got here — and where we can go next.
SmarterDx key perspective: Surviving in UM means doing more than humanly possible just to get by. Clinicians make high-stakes status determinations across dozens of complex cases each day, creating significant risk for inconsistency and missed opportunities. Health systems need technology that surfaces clinical evidence and medical necessity alignment earlier to help reduce the burden of manual chart review.
Debi Halverson, RN:“The workload is just unsustainable. A single UM nurse reviews 25–30 charts a day — and each review takes up to an hour. There are only 24 hours in a day…that math doesn’t add up. To manage, you end up rushing reviews, missing important details, and sometimes mis-statusing patients.”
Ruben Amarasingham, MD:“Utilization management has historically been a siloed process where health systems have had to allocate dedicated staff to review patients as they’re coming into the hospital and decide: Do they qualify for inpatient status? Do they qualify for continuing to be in the hospital? That takes a lot of clinical resources.”
Fawaz Habeeb, MD, CMPC, CCDS:“A person has finite cognitive capacity and mental bandwidth, and UR work is exhausting and fatiguing. On top of that, regulatory changes and aggressive payer practices all work together to create a situation where it’s quite challenging to carry out work in a consistent, high-quality way, every day.”
Jeannine Raymond MS, RN:“Dedicated UM teams are common in larger health systems, but less so in smaller and community hospitals. There, case managers frequently absorb UM responsibilities in addition to their existing duties, creating operational and staffing pressures.”
SmarterDx key perspective: AI is transforming healthcare, especially for payers that automatically identify documentation gaps to immediately deny claims. Health systems need tools that surface level-of-care recommendations so that medical necessity is clear before a denial can occur.
Debi Halverson:“Everybody is afraid of denials, but insurance companies deny anything that they can. Denial rates are going up not because the hospitals aren't doing well or they aren't doing the right thing…it’s that insurance companies are of the mindset that if they deny, your facility might not have a utilization management department or a denial department and so you won't fight that denial.”
Fawaz Habeeb:“Payers will say denials are legitimate due to lack of documentation and lack of actual medical necessity. Essentially, they’ll say that bits of crucial information are missing and then deny the claim — but that’s not technically true.
For example, let’s say a patient is in hospital and the doctor is managing their abdominal pain and vomiting. That patient’s diabetic gastroparesis is the underlying cause of the symptoms. Every time the physician writes a progress note, it’s to document the current status of the symptoms — what the clinical team needs to know. They don’t always write that the vomiting and pain are due to diabetic gastroparesis, because that’s a given. But not saying that every time you document, which is very common, leads to denials and flags for lack of medical necessity.”
SmarterDx key perspective: The goal of clinical documentation has evolved far beyond its original purpose of facilitating communication between clinicians. To satisfy the requirements of payers and regulatory agencies, health systems need technology that breaks down silos and enables faster, more accurate utilization and coverage decisions, reducing administrative burden.
Fawaz Habeeb:“Historically, clinical documentation was meant to be a form of communication between clinicians. You didn't have all these other stakeholders — quality reporting agencies, payers, regulatory agencies, CMS and so on and so forth that were scrutinizing it. Physicians and nurses are not trained to document with this level of stringency. They’re trained to document in order to communicate with other clinicians, not to defend claims to payers.”
Naseem Amara, MD:“Now, it’s basically just an arms race. Providers have to get more and more ammo to prove their case and then payers go get more and more ammo to deny those cases.”
Ruben Amarasingham:“You could write your note one way and it makes the determination for utilization management take five seconds, or you could write it another way and it makes the determination take an hour — and you’re still probably going to get it wrong.”
SmarterDx key perspective: Clinicians need to focus on patient care, not tracking denials, managing appeals, or navigating payer processes. For health systems, this starts to become impossible without help from solutions that surface supporting clinical evidence at the point of care — which can prevent denials before they occur.
Debi Halverson:“With a lot of small community hospitals there will be one nurse that’s doing so much. Oftentimes, the denials weren’t even sent to them. And with most denials, you have to address them within a certain amount of time. You also have to do a peer-to-peer review within a specific time frame.
If the denial isn’t sent to your facility, you can't fight it. If you don’t have physician to review it, you can’t do peer-to-peer review. So then at these health systems, they just would downgrade everybody once they got a denial. They would just downgrade it automatically in order to get a payment.”
Naseem Amara:“The priority in the ER is stabilizing the patient — not proving to the payer that the patient is sick. Providers understand that they're going to write notes and document care, but the first priority is to actually get stuff done and take care of the patient and keep them safe.
So they tend to see the payer as sort of the enemy and someone that's blocking them taking good care of their patients. Of course there are always cases of overuse, and waste or fraud, but the majority of time, physicians are really trying to just take care of the patient and they feel that the payer's coming in and blocking them.”
SmarterDx key perspective: The value of UM teams can’t be understated. They need to be able to focus their attention where it adds value instead of wasting clinical resources reviewing cases where determinations are clear. AI can help health systems work strategically through reviews so teams work smarter, not harder.
Jeannine Raymond:“In a perfect world, you’d have a strategic, targeted approach to UM where you’re not reviewing 100% of cases — because not all cases need review. Instead, you’d have a system that helps you identify and focus on the cases that matter most.”
Naseem Amara:“Payers and health systems are both spending inordinate amounts of money and resources — a huge portion of our health care budget goes to this arms race. But there are tons of areas of very clear medical necessity agreement. And if there was just a more cohesive effort to find these areas of agreement, such as identifying certain codes that don’t warrant prior authorizations or certain scenarios that can be auto-approved, rather than pitting everybody against each other, everybody would spend less money and it would be a win-win all around.”
Debi Halverson:“If we could have a smooth UM workflow that lets us know which patients need review — that would be great. There are certain cases we just don’t need to review. A patient who is intubated? They are going to be inpatient. Someone with appendicitis? Maybe they need a review, but it should be quick, they’re probably outpatient. So “better” in UM would be making that type of workflow happen.”
Ruben Amarasingham:“Where possible these determinations should be handled at the point of care so that a lot of downstream processes are unnecessary. That will reduce the need to have that separate silo. Later, if you had systems that enabled you to achieve 100% review because you're assisted by AI systems, major reimbursement gaps could be closed.”
