Where Claims Go Wrong
Rejections and short payments almost always trace back to a small number of causes: eligibility not verified, pre-authorisation missing or delayed, documentation incomplete, coding or package mismatch, and submission after the deadline. Each is preventable with a defined workflow.
Build the Workflow
1. At registration. Capture policy details, verify the patient is covered for the planned service, and note the panel's rules and limits. Flag exclusions early so the patient is not surprised at discharge.
2. Pre-authorisation. Raise it as soon as the plan is known. Track every request with its status and the response deadline. A visible pre-auth tracker with due-date alerts stops the most expensive failure: doing the procedure before approval.
3. During care. Document to the standard the insurer expects: indication, notes, investigations, procedure details, and consumables. Missing justification is a top rejection reason.
4. Billing and submission. Map services to the correct package or codes. Attach the full document set. Submit within the panel's window; a claims calendar with deadlines prevents time-bar rejections.
5. Denial management. Log every rejection with its reason code. Analyse monthly: which panels, which reasons, which doctors or procedures. Appeal with the missing evidence, and fix the upstream step so it does not recur.
The KPIs to Watch
- Clean-claim rate: claims paid without a query.
- Rejection rate by panel and by reason.
- Days in AR: how long insurer money takes to arrive.
- Appeal success rate.
Software Support
Your system should track pre-auths with alerts, enforce a document checklist before submission, hold panel-wise rate tables, and age insurer receivables. If any of that lives in a spreadsheet, that is where claims will leak.