# The claims came back for eleven reasons. Everyone thought there were hundreds. — Radexus

> First-pass denial was treated as an unavoidable cost of doing business with payers. It turned out to be a short, countable list of preventable causes.

*Source: https://radexus.com/cases/denial-pattern/*

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[Success stories](https://radexus.com/cases/)  /  Hospital group

# The claims came back for eleven reasons. Everyone thought there were hundreds.

- Sector: **Hospital group**
- Scale: **South India, four hospitals**
- Duration: **3 quarters**
- Number agreed: **First-pass acceptance**

In this success story
- [The definition](#h-0)
- [The build](#h-1)
- [The result](#h-2)

First-pass denial was treated as an unavoidable cost of doing business with payers. It turned out to be a short, countable list of preventable causes.

Four hospitals under one group, billing across a dozen insurers and TPAs. Denials were handled by a rework team that was good at its job and had no view of the pattern, because each denial was worked and closed individually and nothing aggregated.

Ask anyone in the billing office why claims get denied and you get a long list. Count the denials and the list is short: eleven causes accounted for most of the volume, and eight of those were preventable before submission rather than after.

Nothing in this engagement touches a clinical decision, and we would not have taken it if it did. The work sits entirely in documentation completeness and payer-specific submission rules.

## The definition

**First-pass claim acceptance rate**: claims accepted on first submission without rework, per payer, per hospital. Excluded: claims where the patient was ineligible at the time of admission, and claims disputed on clinical grounds, which are a different problem and not ours.

## The build

Extraction across submitted claim packs, resolved to payer and policy type, checked against the rules each payer actually applies rather than the rules they publish. Missing documents are flagged before submission, on a queue the billing team works, with the specific rule cited so the flag can be argued with.

The citation matters more than the flag. A billing executive who is told a document is missing will comply for a week. One who is shown which payer rejected which claim for which reason last month will change how they work permanently.

## The result

First-pass acceptance rose sixteen points over three quarters. Rework hours fell about forty percent, and the group's finance head reported the cash flow effect as more valuable than the cost saving, because it moved receipts forward by weeks across the whole book.

**First-pass acceptance**Number agreed, claims accepted without rework

**+16 pts**Result at 3 quarters, on first submission

**Down 40%**Rework hours, in the billing team

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