Questions about hospital billing and claim denials

A denial ("glosa" in Brazil) is the payer's full or partial refusal to pay an item on the hospital account, for technical reasons (procedure without justification, quantity above expected) or administrative ones (missing authorization, registration error, deadline). See the article hospital claim denials.

The most common are administrative (documentation, authorization, registration or deadline failures), technical (questioning the need for or quantity of what was done) and linear (a cut applied without item-by-item analysis). There is also a distinction between an initial denial, which can be appealed, and a final denial.

By measuring them by payer, reason and department to tackle what concentrates value first; checking authorization and documentation before submission (pre-billing); keeping payer price tables up to date; and appealing undue denials on time. Details are in the article hospital claim denials.

By tracking every day the value and age of accounts with completed care that have not been billed, by department and payer, and setting a maximum time for each stage. In Clic Health, the Daily Pending Accounts dashboard shows these accounts and their protocol status. See unbilled accounts.

A denial is the refusal to pay an item, which can still be appealed. A write-off is the amount the hospital recognizes it will not collect, after appeals are exhausted or for other reasons. Clic Health's Write-offs dashboard shows accounts billed as losses.

BI shows where denials are, what they cost and how they evolve, which makes prioritization possible. The fix happens in the billing process: documentation, authorization, registration and appeals. BI's gain is directing the team's effort.