IMPLICATIONS OF MANAGED CARE DENIALS FOR PEDIATRIC INPATIENT CARE

With the growing penetration of managed care into the healthcare marke t, providers continue to experience increasing cost constraints. In th is environment, it is important to track reimbursement denials and und erstand the managed care organization's rationale for refusal of payme nt. This is especially critical for providers of pediatric care, as ch ildren justifiably have unique healthcare needs and utilization patter ns. We developed a system for tracking and documenting denials in our institution and found that health maintenance organizations denied cla ims primarily for one of three reasons: medically unnecessary care, ca re provided as a response to social (rather than medical) need, and pr ovider inefficiencies, Health maintenance organization denials are als o growing annually at our institution. This knowledge can not only hel p providers of pediatric care more effectively negotiate future contra cts, but provides an opportunity to differentiate the health needs of the pediatric patient from those of the adult,This information can be used as a basis for education, pediatric outcome studies, and guidelin e development-all tools that can help providers receive reasonable rei mbursement for pediatric services and enable them to meet the complex health needs of children. Recommendations for action are discussed.