Problem Statement

Payer denials require staff to research each account, gather supporting information, and rework or appeal the claim before timely-filing deadlines pass. Because the large majority of denials are avoidable and every unworked account risks becoming a write-off, this manual follow-up is a direct, ongoing drain on recoverable revenue. When the coverage filing order on the Professional Billing (PB) side doesn't match the Hospital Billing (HB) side, the hospital claim pays and the professional claim denies for coordination of benefits (COB). The paid HB claim already shows the correct order, so the fix is known, but each account still has to be opened, compared, corrected, and resubmitted manually. At roughly 461 accounts a week and about five and a half minutes each, the volume built a backlog of avoidable accounts receivable.

Automation Solution

This automation works the COB denial workqueue, reads the coverage filing order on the paid HB account, updates the PB coverage to match, and resubmits the claim.