The popular advice is simple: work denials faster, add staff, and push more appeals through the queue. That approach can recover some cash, but it treats the visible symptom as the business problem. A denial is often
The popular advice is simple: work denials faster, add staff, and push more appeals through the queue. That approach can recover some cash, but it treats the visible symptom as the business problem. A denial is often
A patient arrives for a scheduled procedure at a hospital they deliberately chose because it's in network. The surgeon is in network. The facility is in network. Later, the anesthesia claim is processed as out of network,
The American Hospital Association reported that Medicare and Medicaid underpayments totaled $100.4 billion in 2020, up from $75.8 billion in 2019. Medicare payments covered only 84 cents per dollar of hospital cost, while Medicaid covered 88 cents,
A clean claim arrives with the right diagnosis, the right modifiers, and complete documentation. The payer processes it, but the payment lands below the contracted amount. Nobody can immediately say whether the cause was an outdated fee
A new specialist starts Monday. The schedule is full, the clinical team is ready, and patients have already been referred. Then the practice manager discovers that the provider's payer enrollment isn't complete. The clinician may be able
More than 1.46 million disputes were initiated under the No Surprises Act independent dispute resolution process in 2024, more than double the prior year's volume and more than seven times the 2022 level, according to the Congressional
Most physician practices are told to fix revenue cycle management by attacking denials. That advice is incomplete. Denials are visible, easy to count, and naturally create work queues, while silent underpayment, payer downcoding, bundling edits, and unreconciled
In U.S. ACA Marketplace plans sold through HealthCare.gov, insurers denied 19% of in-network claims and 37% of out-of-network claims in 2024, producing a combined average denial rate of 20%. KFF estimated that roughly 85 million in-network claims
A claim can fail after a clinically appropriate service, accurate documentation, and correct coding because one identifier doesn't match the payer's record. The patient was seen, the procedure was performed, and the practice did its work. Yet
The most dangerous timely filing denial is often attached to a claim that was coded correctly, medically necessary, and fully covered. A claim can still become uncollectible because the payer received it after its filing window closed.
