Welcome to The Edge of Healthcare, your premier destination for insightful discussions and actionable insights. In each episode, we dive deep into conversations with industry leaders, exploring the dynamic landscape of healthcare. From overcoming hurdles to embracing breakthroughs, join us as we discover firsthand the strategies and experiences of healthcare trailblazers. Whether it’s payer and health system leaders or innovative solutions, we’re here to empower you with knowledge that drives real change in the industry. Don’t just listen—be part of the transformation.
About This Episode
A hospital can deliver the care, document it, pay its staff and its labs for it, and then spend three months proving all over again that the care was necessary.
In this episode, Gretchen Heinen, CEO and co-founder of Authsnap, talks about why the clinical denials process cannot scale on human effort alone. She walks through what it takes to fight a single medical-necessity denial, starting with the five ways a payer might tell a hospital the money isn’t coming and ending with a hand-built appeal letter that draws on the chart, the payer policy, the plan, and state law. She describes the chemotherapy case that pushed her to leave the work and build software for it, and explains why her success rates swing from 12% to 85% depending on how organized the hospital sending her the claims is. She also argues that technology alone makes the problem worse, because a workforce that never learned the underlying skill can’t recognize when the software is wrong.
Tune in to hear why Gretchen thinks the fix starts with hospital leaders being honest about how badly they’re struggling!
About Gretchen Heinen:
Gretchen Heinen, RN, BSN, is a former hospital nurse case manager with deep expertise in prior authorization, denials, and care management. After years at the bedside, specializing in reducing avoidable admissions and optimizing resources, she transitioned to the business side to tackle systemic barriers in healthcare. Driven by a passion for women founders and nurse-led innovation, Gretchen founded Authsnap after a decade of witnessing the devastating impact of denied claims on patient lives.
Resources:
- Connect with and follow Gretchen Heinen on LinkedIn.
- Learn more about Authsnap on their LinkedIn and website!
Things You’ll Learn:
- A payer can communicate a denial in at least five ways, including a letter in the mail, a smaller deposit in the bank account, a UB-04, an 835, or a remittance advice, so hospitals lose time simply identifying what was denied.
- Hospitals typically wait 2 to 4 weeks to be notified of a denial and another 4 to 8 weeks to fight it, which means roughly three months without payment for care already delivered.
- Human-written appeals succeed 60% to 70% of the time on average; Authsnap has reached 85% with one customer and 12% with another whose claims came in with the wrong payers and missing information.
- One year of 835 data at a small rural hospital surfaced $500,000 in a single denial category, all tied to authorizations that were never requested before the procedure.
- Getting technology into a hospital can take 12 to 24 months and as many as 12 sign-offs, up from the 4 or 5 required in the past, though Authsnap has onboarded customers within 48 hours and within nine days of a first discovery call.
Read the transcript below and subscribe to The Edge of Healthcare on YouTube.
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