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.