Rework and Refunds from Denied Lab Claims Due to Coding Defects

$1,000,000-$5,000,000+ (government program scale: audit labor, corrective action oversight, legal costs if network exclusion required; estimated across all Medicare/Medicaid programs) • $100,000-$500,000 annually per large payer (staff labor: 3-5 FTE @ $60,000/year reviewing lab claims = $180,000-$300,000; plus cost of member communication and dispute resolution) • $12,000-$25,000 annually per practice (300-500 claims/month × 5-8% denial rate × $150-250 average reimbursement value; plus labor cost of rework at $35/hour × 250 annual rework hours)

Billing staff manually review payer remittances and denial codes, keep informal cheat-sheets of payer-specific coding rules, rework denied claims one by one, and track appeals and refunds in Excel or Google Sheets instead of an integrated denial-management engine. • Billing teams export denial reports from hospital billing systems or clearinghouses, reconcile them in spreadsheets by client and test, and manually correct coding or request updated diagnoses from hospital HIM/coding departments via email and ad‑hoc portals. • Client services builds ad hoc reports in Excel from the LIS/RCM to show denial patterns by provider, then manually organizes conference calls and email threads with coding and sales to triage and correct future orders.