Claim Recovery Made Easy: Automating Denial Management with expEDIum RCM

• Are claim denials silently draining your revenue?
• Is your billing team spending hours on repetitive follow-ups and appeals instead of focusing on patient care?
• Do you struggle to identify patterns in denials or figure out how to recover lost revenue efficiently?

These are challenges many healthcare providers face. In 2023, insurers under the Affordable Care Act denied an average of 20% of in-network claims, with some carriers denying up to 33%. For a multi-specialty clinic or Ambulatory Surgery Center (ASC), this can translate to thousands of dollars in lost revenue every month — not just from the denied claim itself, but from the additional administrative time and costs involved in resolving them.

In this blog, we’ll explore how automating denial management can streamline your claim recovery, minimize revenue leakage, and allow your billing teams to focus on value-driven work. We’ll discuss common pain points, the role of automation, and how expEDIum’s RCM solutions empower providers to handle denials effectively.

Understanding the High Cost of Claim Denials

Claim denials are more than just rejected claims — they are a drain on resources, time, and revenue. According to the American Hospital Association, hospitals and health systems spent approximately $19.7 billion in 2022 on processes related to denied claims. This includes labor hours spent on appeal letters, phone calls, resubmissions, and auditing rejected claims.

Some of the most common causes of claim denials include:

• Coding Errors – Using outdated or incorrect CPT or ICD-10 codes.
• Eligibility and Coverage Issues – Submitting claims for patients whose insurance is expired or changed.
• Authorization Failures – Lack of prior authorization for certain procedures.
• Timely Filing Limits – Claims submitted past the allowed filing window.
• Incomplete Documentation – Missing clinical notes, consent forms, or other required information.

The challenge is not just in the denials themselves but in identifying patterns and preventing future issues. Manual tracking often leads to repetitive mistakes, missed deadlines, and frustrated staff.

Why Automation is the Key to Efficient Denial Management

Automation is no longer optional in revenue cycle management — it’s essential. Here’s how automated denial management transforms the claims recovery process:

1. Automated Claim Scrubbing

One of the main reasons claims are denied is human error in coding. Automated claim scrubbing checks for coding accuracy, missing fields, and inconsistencies before submission. This proactive approach reduces errors and prevents many denials before they even reach the payer.

2. Real-Time Eligibility Verification

Automation enables real-time verification of patient insurance details, including coverage status, copays, deductibles, and plan restrictions. This reduces eligibility-related denials and ensures claims are submitted with correct patient data from day one.

3. Prior Authorization Tracking

Many payers deny claims due to missing prior authorizations. Automated systems track authorization requirements, send alerts, and maintain documentation, so staff never miss a necessary approval. This reduces delays and ensures compliance with payer requirements.

4. Timely Filing Alerts

Even a correctly coded claim with proper documentation can be denied if submitted late. Automation helps monitor submission deadlines, alert staff of upcoming filing windows, and prioritize claims at risk of late submission.

5. Data-Driven Denial Analysis

Automated platforms generate actionable insights by analyzing denial trends and recurring patterns. By identifying root causes, providers can implement corrective measures, optimize workflows, and prevent similar denials in the future.

Real-World Success: Automation in Action

Consider Omega Healthcare Management Services, a revenue cycle management firm supporting over 350 healthcare organizations. By integrating AI and automation into their workflow, Omega dramatically improved efficiency:

• Reduced manual documentation time by 40%
• Cut turnaround time for claims by 50%
• Saved over 15,000 employee hours per month
• Achieved 99.5% accuracy in claim submissions

This example demonstrates how automation not only improves financial outcomes but also frees staff to focus on higher-value tasks, such as reviewing complex claims, patient support, or strategic revenue initiatives.

How expEDIum RCM Simplifies Denial Management

At expEDIum, our Revenue Cycle Management (RCM) platform integrates automation to streamline claim recovery and denial management. Here’s how:

• Integrated Claim Scrubbing: Checks for coding errors, missing fields, and payer-specific rules.
• Real-Time Eligibility Verification: Ensures all patient information is accurate and up-to-date.
• Prior Authorization Management: Tracks required approvals and alerts staff to upcoming deadlines.
• Timely Filing Alerts: Keeps your team on top of submission deadlines to prevent late denials.
• Denial Analytics: Offers detailed reports on denial patterns, root causes, and actionable insights.

By leveraging these tools, providers can recover lost revenue faster, reduce administrative overhead, and improve operational efficiency without overburdening their teams.

The Business Case for Automation

Why invest in automated denial management?

1. Revenue Protection: Recover claims faster and prevent future denials.
2. Operational Efficiency: Reduce manual labor, paperwork, and repetitive tasks.
3. Improved Compliance: Ensure all claims meet payer requirements.
4. Data-Driven Decisions: Identify bottlenecks, common errors, and training opportunities.
5. Better Patient Experience: Spend more time focusing on patient care instead of administrative tasks.

The cost of implementing automation is typically outweighed by the revenue recovered and efficiency gained, making it a strategic investment for practices of all sizes.

Moving Forward: Best Practices for Denial Prevention

1. Standardize Coding and Documentation: Ensure your staff follows consistent procedures for entering claims.
2. Leverage Automation for Repetitive Tasks: Preemptively flag errors, verify eligibility, and track authorizations.
3. Analyze Denial Patterns Regularly: Use analytics to identify recurring issues and implement corrective actions.
4. Train Staff Continuously: Keep up with payer requirements and coding updates.
5. Integrate Technology Seamlessly: Use platforms like expEDIum RCM to combine automation, analytics, and workflow optimization.

Conclusion

Claim denials are an unavoidable part of the revenue cycle, but they don’t have to be a revenue drain. Automating denial management provides a strategic advantage, enabling healthcare providers to recover lost revenue, reduce administrative burdens, and focus on patient care.

Automation is not just about technology — it’s about creating a system that proactively prevents errors, monitors claims, and provides actionable insights. For practices seeking efficiency, accuracy, and financial stability, adopting automated denial management is a must.

Take the first step toward revenue recovery today. Explore how expEDIum RCM can streamline your claim recovery process, reduce denials, and optimize your revenue cycle management.