Rethinking Denials: Why Claims Transparency Benefits Us All

Hospitals and physician practices — especially those managing complex service lines like wound care — are under enormous pressure to deliver quality care while managing rising costs, staffing shortages, and evolving compliance demands. Among the greatest threats to financial stability today? The sharp rise in claim denials — many of which come from commercial payers operating behind a veil of algorithmic decision-making.

While the push for price transparency has made headlines and gained traction across the healthcare industry, one critical area remains largely unexamined: payer transparency. And it’s time we start talking about it.

The Burden of Denials on Providers and Patients

For high-integrity healthcare organizations — those striving to do things the right way — the current climate creates a perfect storm. Claims are denied for increasingly vague or inconsistent reasons. Appeals drag on for months. And the financial burden of these unpaid claims ultimately falls on the hospitals, providers, and patients caught in the middle.

Recent investigations have raised red flags about the use of artificial intelligence (AI) and automated algorithms by some commercial insurers — systems allegedly trained to rapidly deny claims en masse with limited human oversight. If these reports are accurate, it’s more than a billing issue — it’s an operational and ethical one.

In wound care, these denials often target high-cost, high-value services like cellular and/or tissue-based products (CTPs), negative pressure wound therapy (NPWT), and even hyperbaric oxygen therapy (HBOT) — procedures that are medically necessary but frequently flagged by payer systems.

What If Providers Had Access to the Same Algorithms?

Imagine a world where healthcare providers could test their claims against the same rulesets insurers use before they hit "submit."

By granting limited, read-only access to the denial algorithms or even offering a sandbox environment for claim testing, payers could empower providers to:

• Proactively identify coding issues

• Submit cleaner, more accurate claims

• Reduce appeals and delays

• Improve payer-provider trust

  
  

This wouldn’t just improve revenue cycle performance — it would realign both sides toward a common goal: getting patients the care they need, supported by timely reimbursement.

A New Standard for Claims Integrity

At Shared Health Services (SHS), we believe accountability should run both ways. We work closely with hospital partners to strengthen documentation, navigate complex billing guidelines, and improve claim accuracy from the inside out. But even the best-prepared teams are vulnerable in a system where payers operate behind closed doors.

Transparency doesn’t mean confrontation — it means collaboration. And when providers have access to the same tools used to evaluate their work, the result is a smarter, fairer process for everyone involved.

Final Thought: Transparency Is a Shared Opportunity

Commercial payors have a responsibility to uphold efficient and accurate claims processing — and providers are equally committed to submitting compliant, well-documented claims. But when the rules used to review those claims are opaque or automated without context, even high-quality submissions can fall through the cracks.

Transparency doesn't mean revealing trade secrets or upending systems. It simply means giving providers the ability to understand — and prepare for — how their claims are evaluated.

As the healthcare industry continues to evolve, creating space for shared clarity and collaboration could reduce denials, ease administrative burden, and ultimately benefit the patients we all serve.

Shared Health Services: Your Ally in Billing, Coding, and Compliance

With more than 25 years of experience in wound care and hyperbaric program development, Shared Health Services equips hospitals and healthcare providers with the resources, tools, and peer-to-peer expertise needed to build successful, sustainable HBOT and wound care programs.

We work directly with center staff — serving as trusted liaisons — to provide clinical guidance, billing and coding support, and documentation coaching aligned with the highest standards of care. Our goal is to empower teams, elevate outcomes, and strengthen local efforts through proven strategies and responsive, partnership-based support.

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