In today’s complex health care environment, in which CMS and insurers each maintain their own claims-related “rules,” disputes, DRG downgrades and denials are all-too common.

Recent studies show that up to one out of every five claims is delayed or denied, and in certain categories (such as operating room services and laboratory tests), one-quarter to one-third of claims are rejected. Some providers concede defeat: they fail to re-submit claims or appeal denials altogether, simply because each such effort adds to their already-high administrative costs.

Finance and RCM leaders need concrete tools to prevent, identify and resolve claims disputes efficiently and cost-effectively.

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