Delayed Reimbursements from Prior Authorization Denials and Rework

$100,000-$250,000 annually (Medicaid denial rate 15-20%; unresubmitted claims) • $100,000-$300,000 annually (delayed reimbursement + staff overtime for follow-ups) • $100,000-$350,000 annually (lost revenue; staff overtime; AR aging)

Compliance Officer builds carrier-specific approval checklists and tracks comp-related denials manually, often handling exceptions one by one with adjusters via calls and emails. • Compliance Officer cobbles together state Medicaid PA rules and managed Medicaid plan bulletins in spreadsheets and distributes them to staff, relying on spot checks of denied claims to refine the guidance. • Compliance Officer compiles Tricare authorization policies and distributes static summaries, then manually intervenes on problem claims and appeals when patterns of denial emerge.