Claim Denials from Failed Eligibility and Medical Necessity Verification

$10,000-$40,000 per month in denied claims from missed pre-auths and coverage gaps; unbilled tests; rework costs • $100,000–$500,000 annually from claims denied for bad or missing eligibility information captured at the draw, many of which are never corrected or rebilled. • $100,000–$600,000 annually in unreimbursed professional and technical pathology services tied to eligibility and medical necessity denials.

Billing and compliance staff manually compare orders against CMS LCD/NCD policies in PDFs or websites, maintain homegrown Excel matrices and cheat sheets for covered diagnoses, and run one-off eligibility checks on payer portals after service. • Billing managers and teams use spreadsheets and color-coded trackers to organize denial types by payer and test, manually appeal selected cases, and tweak billing edits based on retrospective analysis. • Billing managers generate payer-specific denial worklists, manage rebills and appeals in Excel trackers, use mail or fax for appeals, and prioritize only higher-dollar cases for intensive follow-up.