Getting Paid for Work the Clinic Has Already Done
A rejected claim is unpaid work that already happened. We built a claims desk that checks a file against the insurer’s own rules before it is sent, so acceptance is a property of the submission rather than a hope.
Clinics and dental groups · insurance back office
healthcare!The Need
A clinic treats a patient, then has to convince an insurer to pay for it. The paperwork arrives as email attachments and portal downloads in no particular order, each insurer applies its own coverage rules, code sets, deadlines and document requirements, and a file that is missing one item comes back weeks later as a rejection. By then the treatment is long finished, the administrator who assembled the claim has moved on to other work, and the practice is chasing money for something it has already delivered. The failure is rarely a wrong diagnosis code; it is an incomplete submission nobody had the time to check line by line against a rulebook that differs per insurer.
The Approach
We built a claims desk that owns the file from arrival to payment. Incoming documents are opened and classified on receipt, so nothing sits unread in an inbox waiting to be noticed. Each claim is then checked on the dimensions that actually decide acceptance — coverage, supporting documents, codes, deadlines and amounts — and checked against the specific insurer’s own rules rather than a generic template, because a submission that satisfies one payer can be incomplete for another. The point of the design is that first-pass acceptance is produced by construction: the desk will not present a file as ready while a required element is missing, which moves the discovery of a gap from the insurer’s rejection letter to the moment of assembly. Patient and policy data are handled as the regulated material they are rather than as ordinary attachments.
