Claim Denials from Coding Errors and Documentation Issues

$100,000-$150,000 annually per mid-sized clinic from claim rework overhead, resubmission delays extending DSO 15-30 days, administrative labor for manual remediation (estimated 8-12 hours weekly), and written-off revenue from claims exceeding appeal windows • $100K-$150K annually in delayed reimbursements, staff rework labor costs, and unbilled revenue per mid-sized school district clinic; additional $15K-$25K in administrative overhead for appeal processing • $100K-$160K annually (Medicare is high-volume, high-value; each denial = lost revenue; resubmission admin is significant)

Billing Specialist maintains manual spreadsheet of Medicaid MCO behavioral health coding rules by plan, manually references payer websites to check current rule status before submission, tracks denials in separate spreadsheet, manages rework queue manually, often resubmits claims with minimal changes after denial • Billing Specialist maintains separate VA code lookup spreadsheet, manually verifies each claim against VA requirements before submission, escalates via phone to VA contractors • Billing Specialist manually references Medicare psychiatric CPT code requirements (from outdated CMS documentation or practice memory), reviews patient files to confirm medical necessity documentation exists, manually identifies claims needing re-work, maintains spreadsheet of Medicare denial codes and resolution paths