Claims Denial Management for Hospitals

Improve first pass rate with significant reduction in Claims denials. Currently Hospitals claims denial range from 15-20%. Reduce Admin cost by automation and BPO model.

Detailed Process:


  • We start with historical claims to be run against HiPaaS Clinical editing database and machine learning rules to review the patterns.
  • HiPaaS Clinical editing database contains data from various sources CMS(Medicare CCI, MUE, Follow-up days, Modifiers, LCD, NCD etc.), Medicaid (State’s Medicaid Payment/ clinical editing policies) and  appropriate Payers payment policies.
  • HiPaaS will Recommend/Provide correct coding guidelines/suggestion and flag the edits prior to sending it to Payer and it can be corrected prior to sending the Claims.
  • Could be enhanced to configure Rate/Fee as per provide contract to track payment alongside.
  • Could be enhanced to link with various Groupers to test the claim correctness for APC, APG, APR-DRG, MS-DRG, LTC/SNF etc.
  • This is be cloud based and light weighted system with dynamic validation and regular database update.
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  • Get running in days
  • HIPAA Cloud APIs and fully managed services
  • Quickly enable Healthcare API’s (200+ API out of box)
  • Quickly automate HL7, X12 integrations
  • Quickly automate data reconciliation or compare healthcare data
  • Quickly Digitize by exposing data over interactive dashboard
  • Dashboard and Analytics capability
  • Accelerators for code development
  • Full Managed Services model
  • Extremely cost-effective
  • Lightweight to get started
  • Standards based integration
  • Cloud based hosting with AWS or On Premise