Reducing Insurance and TPA Rejection Rates

I have been on both sides of insurance company denial process for decades; as a practicing physician, hospital and health system CMO, Vice President of Medical Affairs for a physician owned health insurance company and medical director of risk bearing health system management services organization that has delegated utilization management. I learned how to reduce denials to near zero. Here are my top ten tips to avoid denials. 1. Most denials are simply due to referral to a non-contracted provider. Be sure you refer patients to contracted in-network providers. 2. Many denials are for non-covered benefits. For example, there are many things that Medicare doesn't cover like diapers or TED hose. Know what is covered and what isn't. 3. Many denials have errors; incorrect CPT and ICD 10 codes, wrong dates of service etc. Make sure your billing staff knows what they are doing 4. Many denials are because what is requested doesn't align at all with the medical literature or guidelines. Base your diagnostic and therapeutic decisions on peer reviewed medical literature. When in doubt, consult UPTODATE 5. Many denials are for unnecessary and hideously expensive brand name drugs. Prescribe generics whenever possible 6. Many denials are for unnecessary imaging. Always refer to the American College of Radiology Imaging Appropriateness Criteria when considering high tech imaging 7. Many denials are because of excessive radiation exposure in children. Always use Choose Wisely Guidelines and Image Gently Guidelines. Do not expose children to CAT scans if an ultrasound or MRI will do. 8. Many denials are for insufficient or no clinical documentation. Make sure you provide enough history for the physician reviewer to understand what you are requesting and why 9. Some denials are for off-label use of medications. Stick to what the FDA has authorized 10. Some denials are because the request is for an experimental treatment. Insurance companies generally don't fund research!

Most health insurance claims don’t fail because of fine print.They fail because people never read it. In FY24 alone, over ₹26,000 crore worth of claims were denied. Half were reduced or outright rejected. And nearly 80% of policyholders believed their claims were deliberately delayed. But here is one uncomfortable truth : Many of these rejections were preventable. Not with connections. Not with luck. But with clarity, caution, and a bit of groundwork done early. It starts with what you disclose. Even something as minor as borderline cholesterol or controlled BP. Telling your agent verbally won’t protect you. If it’s not documented in your proposal form, it might as well not exist. That one missing line, no matter how unrelated to your treatment can void the entire claim. Understanding waiting periods is another blind spot. People expect instant coverage, but health insurance doesn’t work that way. Accidents are covered from day one. Most hospitalizations come with a 30 day wait. For cataracts, hernias, or joint replacements, it can be as long as two years. And for pre existing illnesses? Three to four. These aren’t tricks, they’re terms. Burying your head in the sand doesn’t make them disappear. Hospital choice matters too. Not all hospitals are treated equally by insurers. Some are blacklisted for inflated billing or unethical practices. And claims from such institutions often end up in the rejection pile. Just a few minutes to verify if your hospital is on the insurer’s cashless list can save weeks of headaches. Then comes paperwork. For reimbursements, be ready to provide everything: prescriptions, discharge summaries, UPI receipts, doctor notes, even the packaging from surgical equipment. A missing sticker from a mesh implant may sound absurd, but it has been the reason for denial before. Pre authorization is another crucial step people skip. Informing your insurer before hospitalization isn’t just a formality, it sets the stage for a smoother process. Track every rupee. Save every bill. Because when the claim investigator says “Show me the money,” they’ll want proof for every paisa. What your doctor writes also matters more than you think. A clearly stated diagnosis and a strong medical justification can mean the difference between swift approval and endless queries. Build rapport. Stay informed. Don’t leave paperwork to chance. And even when you’ve done everything right, sometimes, it still doesn’t work out. That’s when most people give up. But you don’t have to. Your insurer has a grievance redressal system. And above that, there’s IRDAI’s Bima Lokpal. System exists. Use it. There’s no magic wand here. Just readiness. Just responsibility. Because in health insurance, gap between rejection and reimbursement is rarely about paperwork. It’s about whether you knew what to expect in the first place. #HealthInsurance #ClaimSmart #InsuranceLiteracy #FinancialProtection

U.S. dental support organizations (DSOs) are turning to modern revenue cycle management (RCM) technology to tackle costly insurance claim denials and streamline operations. Cloud-based RCM platforms can unify insurance, billing, and patient data across all practices, providing centralized dashboards and real-time analytics. By eliminating redundant systems and automating workflows end-to-end, DSOs gain clearer financial visibility and tighter control over claims. For example, one DSO reports that real-time eligibility verification built into scheduling reduces claim denials and administrative back and forth by catching coverage issues before treatment. These integrated systems ensure patient and payer data flow seamlessly from intake through payment, closing gaps that cause revenue leakage. Automation and AI also play a key role in scrubbing claims for errors before submission. AI-enabled coding tools can interpret clinical notes and automatically assign the correct procedure codes, staying current with the latest coding rules. When errors are caught early, first-pass claim approval rates soar. In fact, industry reports show that intelligent claims engines improve first-pass claim approval rates by validating data and codes against payer rules. This translates into fewer rejections and resubmissions, so billing teams spend less time on appeals. Similarly, automated claims scrubbing has been shown to cut manual claim-cleanup time by over 90%, yielding faster reimbursements and improved cash flow for practices. By reducing human error in coding and documentation, AI tools both reduce the number of denied claims and give staff more time to focus on complex cases. Verifying insurance coverage up front is another critical lever for denial prevention. Modern RCM suites often include real-time eligibility checks that automatically pull patient benefits and deductibles at scheduling. This means patients and staff know expected coverage before work is done. For DSOs, this upfront check is proving powerful: one study found that automating eligibility verification led to an 11x increase in checks and about a 20% drop in denials due to eligibility errors. In practice, real-time verification prevents surprise denials and billing surprises. Patients see transparent estimates, and practices avoid wasted claims submissions. Together with AI-fueled claims validation, real-time eligibility ensures that only clean, complete claims go out the door. Automated RCM platforms with built-in eligibility checks and AI-assisted coding not only slash denial rates, but also signal that the organization is committed to efficiency and growth. In practice, leading DSOs see measurably faster reimbursements, reduced revenue cycle costs, and fewer surprises on the balance sheet. 🔔 Follow me (Sina S. Amiri) for more insights on transforming dental RCM through AI and automation. #Dental #RevenueCycleManagement #ArtificialIntelligence #Tech

𝐇𝐞𝐚𝐥𝐭𝐡𝐜𝐚𝐫𝐞 𝐂𝐥𝐚𝐢𝐦𝐬 𝐃𝐚𝐭𝐚 𝐀𝐧𝐚𝐥𝐲𝐭𝐢𝐜𝐬 𝐒𝐨𝐟𝐭𝐰𝐚𝐫𝐞 Healthcare is losing millions to claim denials. The good news? Most denials are preventable. Here’s how Claims 𝐃𝐚𝐭𝐚 𝐀𝐧𝐚𝐥𝐲𝐭𝐢𝐜𝐬 𝐢𝐬 𝐭𝐫𝐚𝐧𝐬𝐟𝐨𝐫𝐦𝐢𝐧𝐠 𝐫𝐞𝐯𝐞𝐧𝐮𝐞 𝐜𝐲𝐜𝐥𝐞 𝐦𝐚𝐧𝐚𝐠𝐞𝐦𝐞𝐧𝐭: 𝟏. 𝐓𝐡𝐞 𝐏𝐫𝐨𝐛𝐥𝐞𝐦: 𝐈𝐧𝐞𝐟𝐟𝐢𝐜𝐢𝐞𝐧𝐭 𝐂𝐥𝐚𝐢𝐦𝐬 𝐏𝐫𝐨𝐜𝐞𝐬𝐬𝐢𝐧𝐠 🔹 High denial rates lead to massive financial losses. 🔹 Most rejected claims go uncorrected and unresubmitted. 🔹 Lack of root cause analysis means errors keep repeating. 𝟐. 𝐖𝐡𝐲 𝐓𝐫𝐚𝐝𝐢𝐭𝐢𝐨𝐧𝐚𝐥 𝐌𝐞𝐭𝐡𝐨𝐝𝐬 𝐅𝐚𝐢𝐥 ❌ 𝐓𝐞𝐜𝐡𝐧𝐨𝐥𝐨𝐠𝐲 𝐆𝐚𝐩𝐬: No proactive tools to detect early issues. ❌ 𝐏𝐫𝐨𝐜𝐞𝐬𝐬 𝐈𝐬𝐬𝐮𝐞𝐬: Manual data entry and slow insurance verification. ❌ 𝐒𝐭𝐫𝐚𝐭𝐞𝐠𝐢𝐜 𝐖𝐞𝐚𝐤𝐧𝐞𝐬𝐬: No long-term plan to reduce denials. 𝟑. 𝐓𝐡𝐞 𝐏𝐨𝐰𝐞𝐫 𝐨𝐟 𝐂𝐥𝐚𝐢𝐦𝐬 𝐀𝐧𝐚𝐥𝐲𝐭𝐢𝐜𝐬 ✅ 𝐃𝐚𝐭𝐚-𝐃𝐫𝐢𝐯𝐞𝐧 𝐑𝐨𝐨𝐭 𝐂𝐚𝐮𝐬𝐞 𝐀𝐧𝐚𝐥𝐲𝐬𝐢𝐬: Identifies patterns behind denials. ✅𝐈𝐧𝐭𝐞𝐫𝐚𝐜𝐭𝐢𝐯𝐞 𝐃𝐚𝐬𝐡𝐛𝐨𝐚𝐫𝐝𝐬: Visualize denial trends, CPT codes, and payer behaviors. ✅ 𝐀𝐈 & 𝐌𝐚𝐜𝐡𝐢𝐧𝐞 𝐋𝐞𝐚𝐫𝐧𝐢𝐧𝐠 𝐈𝐧𝐭𝐞𝐠𝐫𝐚𝐭𝐢𝐨𝐧: Automate insights and optimize workflows. ✅ 𝐑𝐞𝐚𝐥-𝐓𝐢𝐦𝐞 𝐌𝐨𝐧𝐢𝐭𝐨𝐫𝐢𝐧𝐠: Spot issues early in the revenue cycle. 𝟒. 𝐓𝐡𝐞 𝐑𝐞𝐬𝐮𝐥𝐭𝐬 𝐒𝐩𝐞𝐚𝐤 𝐟𝐨𝐫 𝐓𝐡𝐞𝐦𝐬𝐞𝐥𝐯𝐞𝐬 💰 Reduced denial rates to industry best standards. 💰 Millions saved from preventing lost reimbursements. 💰 Sustained improvements through continuous data-driven strategies. 𝟓. 𝐇𝐨𝐰 𝐭𝐨 𝐌𝐚𝐤𝐞 𝐈𝐭 𝐖𝐨𝐫𝐤 📌𝐄𝐱𝐞𝐜𝐮𝐭𝐢𝐯𝐞 𝐁𝐮𝐲-𝐈𝐧: CEOs, CFOs, and COOs must prioritize claims analytics. 📌𝐃𝐞𝐝𝐢𝐜𝐚𝐭𝐞𝐝 𝐃𝐞𝐧𝐢𝐚𝐥 𝐓𝐞𝐚𝐦𝐬: Root cause analysis experts to track trends. 📌𝐏𝐃𝐂𝐀 𝐌𝐞𝐭𝐡𝐨𝐝𝐨𝐥𝐨𝐠𝐲: A continuous improvement strategy for long-term success. 𝐘𝐨𝐮𝐫 𝐫𝐞𝐯𝐞𝐧𝐮𝐞 𝐜𝐲𝐜𝐥𝐞 𝐬𝐡𝐨𝐮𝐥𝐝𝐧’𝐭 𝐝𝐫𝐚𝐢𝐧 𝐦𝐨𝐧𝐞𝐲, 𝐢𝐭 𝐬𝐡𝐨𝐮𝐥𝐝 𝐦𝐚𝐱𝐢𝐦𝐢𝐳𝐞 𝐢𝐭. If you're looking for 𝐂𝐥𝐚𝐢𝐦𝐬 𝐀𝐧𝐚𝐥𝐲𝐭𝐢𝐜𝐬 𝐞𝐱𝐩𝐞𝐫𝐭𝐢𝐬𝐞, let’s connect and discuss solutions tailored to your organization. 𝐏.𝐒. 𝐖𝐡𝐚𝐭’𝐬 𝐲𝐨𝐮𝐫 𝐛𝐢𝐠𝐠𝐞𝐬𝐭 𝐜𝐡𝐚𝐥𝐥𝐞𝐧𝐠𝐞 𝐰𝐢𝐭𝐡 𝐜𝐥𝐚𝐢𝐦 𝐝𝐞𝐧𝐢𝐚𝐥𝐬? Drop a comment or DM me we’re here to help!