Healthcare organizations face increasing pressure from payers to justify the care they provide, defend medical necessity decisions, and manage the financial impact of denials. For Taylor Smith, Senior Vice President of Business Development at Brundage Group, the challenge isn’t simply preventing denials. It’s helping hospitals recognize when denial avoidance is costing them earned revenue.
With five years at Brundage Group and more than a decade of experience in healthcare, Taylor works closely with hospital leaders to identify opportunities within their utilization management (UM) programs, strengthen Physician Advisor support, and improve financial outcomes.
His perspective is grounded in an important distinction: a low denial rate doesn’t necessarily mean a hospital is doing everything right.
Looking Beyond Denial Rates
In conversations with hospital leaders, Taylor consistently sees the effects of growing friction between hospitals and payers. While denials are often treated as individual reimbursement challenges, payer strategies can influence decisions across an entire organization.
“When organizations focus too heavily on avoiding denials, they can end up playing right into what the payer wants them to do,” Taylor explains. “They’re billing less or not really advocating for the care they’ve been providing.”
This reluctance to challenge payer decisions can create significant revenue leakage. Medicare Advantage plans are a particular concern for many hospitals seeking support, although Taylor emphasizes that these challenges extend across the industry.
Hospitals may interpret a low denial rate as evidence that their UM processes are working effectively. However, they may be overlooking opportunities to appropriately classify patients, defend medical necessity, and capture earned revenue.
Avoiding denials and protecting earned revenue aren’t always the same thing. Recognizing the difference requires hospitals to look beyond familiar metrics and evaluate whether their current processes are supporting appropriate clinical and financial decisions.
Combining Expertise with Technology
Even experienced internal UM and Physician Advisor teams can reach a point where additional expertise makes a difference. Individual hospitals may not have access to the broader perspective that comes from reviewing cases across hospitals, health systems, and payer environments nationwide.
Brundage Group brings that experience to its work, helping organizations identify trends, recognize opportunities, and strengthen their approach to payer challenges.
Technology also plays an important role. Taylor points to Certus Radar™ Revenue Cycle Intelligence as a valuable safety net for hospital UM programs, helping identify patients who may benefit from Physician Advisor review.
The solution grew out of a practical challenge raised by a hospital client: how could the organization ensure the right patients were being escalated when utilization review nurses weren’t available around the clock?
Certus Radar helps direct patients to the appropriate clinical resource, supporting internal teams while helping prevent cases from falling through the cracks during staffing gaps, nights, and weekends.
For Taylor, the distinction is that technology should complement clinical expertise rather than replace it.
“We leverage technology to make sure the right patients are getting to the right resource at the right time,” he explains.
By connecting technology with Physician Advisor judgment, hospitals can better identify opportunities for appropriate patient status determinations and reimbursement. The platform also provides ongoing visibility into results through a dashboard, allowing teams to monitor performance without waiting for monthly reports.
Turning Case Reviews into Lasting Improvement
For Taylor, Brundage Group’s value extends beyond technology and individual case reviews. The team looks for recurring trends in its work, including documentation gaps, denial patterns, and medical necessity decisions, then uses education and feedback to address underlying issues.
“We really work our way out of a job at times by leveraging our work to track those trends and then using education to kind of get past those trends,” Taylor says.
By providing feedback tied to actual cases, Brundage Group helps clinicians and Physician Advisors apply lessons to future decisions. Over time, this can strengthen documentation, improve medical necessity decision-making, and help internal teams become more confident in their approach.
The benefits extend to day-to-day operations, too. When Physician Advisor support helps resolve cases that warrant inpatient status, utilization review nurses can focus more attention on patients who remain in observation. Teams can then investigate whether additional documentation or clinical review is needed or whether a patient may no longer require hospital-level care.
The goal is not simply to improve individual outcomes, but to help hospitals build stronger processes over time.
Standing Behind Clinical Decisions
Brundage Group’s support doesn’t end when a clinical recommendation is made. When a payer denies a claim despite a determination supported by the team’s Physician Advisors, Brundage Group can provide additional assistance through its peer-to-peer program and appeal letter writing.
For Taylor, this support is essential to helping hospitals feel confident advocating for appropriate reimbursement.
“We don’t want denial to be a scary word,” he says. “You just need a partner that’s going to stand behind your determinations and fight those denials appropriately.”
Hospitals should work to prevent avoidable denials, but fear of denials can become costly when it leads organizations to avoid appropriate inpatient admissions or accept payer decisions without challenge. Having experienced clinical support helps hospitals evaluate those decisions and advocate for the care they provide.
Keeping the Focus on Patient Care
Looking ahead, Taylor sees continued opportunity for hospitals to combine their internal expertise with the resources, technology, and broader perspective of an experienced external team. Maintaining a fully staffed internal Physician Advisor program can be challenging, particularly as payer strategies evolve, and staffing needs change.
Brundage Group helps hospitals address these challenges while allowing their clinical teams to focus on patient care.
“Let your physicians do what they do best, and that’s patient care, let us do the business side of medicine.”
– Taylor Smith, Senior VP of Business Development
For Taylor, that mission is what makes his work meaningful. He has seen how stronger UM processes and appropriate reimbursement can help hospitals improve their financial position, sustain growth, and continue serving their communities.
Ultimately, protecting earned revenue is more than a hospital’s bottom line. It helps support the organization’s ability to deliver care and serve patients and families. Through clinical expertise, technology, and ongoing education, Brundage Group helps hospitals recognize opportunities, make informed decisions, and stand behind the care their patients need.
Ready to protect the revenue your hospital has earned?
Connect with Brundage Group to learn how Physician Advisor expertise, Certus Radar, and ongoing education can strengthen your utilization management program and help you stand behind the care you provide.
