Claim Denial Recovery
A tool that tells medical billers which denied insurance claims to fight first, so a clinic recovers the most money with the time it has.
Week by week
Click a week to open its report ·The week at a glance
Where the project is
Four checkpoints from the project brief, and the pipeline the tool is built from.
Checkpoints
From the project brief
The pipeline
How a denial becomes a ranked worklist row
What the data says
Everything below is computed from the dataset I generated: a fictional multi-clinic group billing Medicare, Medicare Advantage, Medicaid managed care and commercial payers. No real patients, providers or clinics.
Claim denial rate by week of service
Share of each week's claims with at least one denied line
Where the money is denied
Denied value at the payer's agreed price, by reason
Time left to appeal
Open denials on the export date (), dollars by days to the deadline
Why each specialty is denied
Denied lines, specialty × reason. Darker = more.
Denial rate by specialty
Claims with any denied line
Denial rate by payer type
Claims with any denied line
Looks like a denial, isn't
What a naive count would wrongly put in the worklist
A denial is a line the clinic absorbs (group code CO) for any reason other than the contractual write-off. Getting this definition right keeps thousands of fake problems out of a biller's queue.
What I've learned so far
The healthcare-billing rules the tool has to get right before any model is useful.
Claims out, remittances back
The practice system builds an 837P claim, a clearinghouse forwards it, and the payer answers 2 to 4 weeks later with an 835 remittance listing what was paid, adjusted or denied.
Who, why, and the detail
Group code says who absorbs it (CO clinic, PR patient, OA other). CARC says why. RARC adds detail. Together they decide the action: fix and resubmit, appeal, write off, or bill someone else.
CO-45 is not a denial
It is the normal gap between list price and the contracted price, on almost every paid line. And $0 paid alone is not a denial either: it can be the patient's deductible (PR-1).
Price a denial at the deal, not the list
The same visit is worth a different amount from each payer. A denial is worth the payer's agreed (allowed) price at most, never the clinic's list price.
Every payer has its own window
Appeal windows run from the remittance date: Medicare 120 days, Medicare Advantage and Medicaid about 60, commercial 90 to 180. After that the money is gone.
Value × odds, per minute of work
A 90% chance at $500 beats a 99% chance at $50. Near-deadline items move up.
Gallery
Charts and screenshots from the work as it happens.