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A claims payer (also known as an insurance company) may deny claims based on individual line-item claim data. This denial generally happens for several

April 1, 2024

A claims payer (also known as an insurance company) may deny claims based on individual line-item claim data. This denial generally happens for several reasons: intake errors on the front end during patient registration, mismatch with diagnosis and procedure coding documented by the health system, or technology issues. If the claim is denied, health systems are required to resubmit the claim, either by correcting the error(s) on the claim or submitting an appeal if they disagree with the denial. Insurance companies may require a resubmission of all original documents. This process is part of the revenue-cycle workflow of a healthcare organization.

This discussion will help you assess the internal and external revenue-cycle workflows and their impact on strategic planning and financial management. It will also enable you to evaluate how the revenue cycle is impacted by insurance plan requirements and regulations and identify front-end, middle, and back-end revenue-cycle processes within operational workflows.

This discussion will help you to prepare for sections 3 (Healthcare Reimbursement), 4 (Revenue-Cycle Process), and 5C (Technology and System Impacts) of the course project.

Imagine you work with a healthcare organization, and you are helping the internal audit team analyze quarterly financial performance. The audit team found several claim denials in the outpatient surgery center and has asked you for a better understanding of the situation.

In your initial post, include the following details:

Explain how technology and human error may contribute to a denial by the insurance company.
Identify at least one internal process breakdown each from the front-end, middle, and back-end workflows that could lead to a claim denial.

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