Automated Denial Documentation Resubmission System to Enhance Revenue Collection and Operational Efficiency

The healthcare organization faces significant manual effort in resubmitting denied insurance claims due to missing or incomplete documentation. These processes are time-consuming, prone to delays, and result in a backlog of claims, leading to revenue losses upwards of millions of dollars annually. Long system load times and cumbersome manual workflows hinder operational efficiency and employee satisfaction.

A mid-sized healthcare provider seeking to optimize claims processing and revenue cycle management through automation.

• Reduce manual labor hours required to process insurance denial re-submissions by automating document retrieval and communication workflows.
• Increase successful claims recoveries by automating denials related to missing documentation (e.g., CO250 and CO252 equivalents), targeting an initial claim processing volume of approximately 3,500 denials annually.
• Achieve a measurable increase in revenue collection, aiming to process over $2 million in denied claims within the first two months post-implementation.
• Enhance employee satisfaction by eliminating tedious manual tasks and enabling staff to focus on complex, higher-value denial types.
• Support digital transformation initiatives and foster a culture of efficiency and innovation within the revenue cycle management team.

• Automated login to healthcare electronic record system and external communication portals.
• Navigation to denial management interfaces and extraction of identified denial records.
• Automated retrieval of relevant medical documentation based on claim date ranges and specific denial criteria.
• Decision engine that evaluates whether documentation meets inclusion criteria for submission.
• Automated downloading and faxing of supporting documentation through integrated communication portals.
• Automatic updating of patient records post-submission with standard notes and closure of denied claims.

• EHR system APIs or interfaces for accessing denial lists and patient documentation.
• External communication portals or fax systems for delivering documentation to payers.
• Logging and audit trail systems for compliance and operational monitoring.

• System scalability to handle an estimated 3,500 denial cases annually with peak processing times optimized for minimal delay (targeting under 10 minutes per transaction).
• High availability and reliability to ensure daily automated runs without failure.
• Data security and patient confidentiality compliance (e.g., HIPAA).
• Auditability of actions taken by automation and detailed logging for compliance and troubleshooting.

The automation initiative is expected to save over 1,000 manual labor hours annually by streamlining denial resubmission processes. It aims to process over $2 million worth of denied claims within the initial two months, significantly reducing backlog and revenue loss. Additionally, it will improve employee satisfaction, support a digital transformation, and enable staff to focus on strategic activities, fostering operational excellence and increased financial performance.