Poor recertification vs discharge decisions due to weak KPI and data visibility

$25,000–$100,000 per year in denied claims, write-offs, and staff time spent reworking claims tied to marginal or inappropriate recertifications. • $25,000–$200,000 per year from revenue leakage on unprofitable episodes • $25,000–$200,000 per year from unprofitable episode extensions

Billing staff build ad hoc spreadsheets to track MA recert intervals, OASIS scores, and visit intensity, then manually review charts whenever a claim is underpaid or denied to see if recert decisions were appropriate. • Clinical Manager and visit clinicians manually pull EMR reports, export to Excel, cross-check with paper notes or memory about patient status and payer rules, and use ad hoc email/WhatsApp threads or hallway conversations to finalize recert vs discharge decisions. • Clinical manager pulls scattered reports from EMR, downloads raw visit and billing data, and manually compiles pivot tables to estimate recert rates and outcomes by diagnosis and payer; then relies heavily on clinician intuition and case conferences to decide recert vs discharge.