🧾
Registration
The cheapest denials to prevent and the most common to find.
- Name mismatch between policy and ID
- Wrong or expired policy number
- Active‑policy status not verified
- Payer or scheme wrongly assigned
Trivicon | Healthcare Quality Consultancy
Denied claims are a process problem, not a billing problem
A claim is rarely denied because of what happened at billing. It is denied because of something that was missed at registration, omitted from the pre‑authorisation, or never written in the clinical record. Resubmitting recovers one claim. Finding the cause stops the next hundred. Trivicon works the second problem — for hospitals, clinics, diagnostic centres and laboratories dealing with insurers, TPAs and government schemes.
Where denials come from
Four points of failure, none of them in billing
Denials cluster. In almost every organisation a small number of causes account for most of the lost value, and each traces back to a specific point in the patient journey. Naming that point is what makes the problem fixable.
📝
Pre‑authorisation
Where high‑value claims are lost before treatment even begins.
- Planned procedure not pre‑approved
- Diagnosis or package code mismatch
- Emergency window missed
- Payer queries left unanswered
🩺
Clinical documentation
The hardest category to fix, and usually the largest by value.
- Discharge summary not matching pre‑auth
- Line of treatment not evidenced
- Progress notes and reports missing
- Admission not justified in the record
⏱️
Submission and follow‑up
Denials created by the calendar rather than the clinical facts.
- Submission window missed
- Mandatory uploads incomplete
- Billing above approved package rate
- Queries not responded to in time
Scheme claims
Government scheme claims fail differently
PM‑JAY, CGHS and ESIC claims are rejected for reasons that have little to do with clinical judgement and a great deal to do with process discipline. They run on fixed workflows with hard deadlines, and the failure modes are predictable enough to design out.
Where an organisation handles both scheme and private claims, the two are assessed separately — the corrective actions are rarely the same.
Typical PM‑JAY failure points
Beneficiary verification
Identity and eligibility not established cleanly at the outset, which invalidates everything downstream.
Package code mismatch
The code on the discharge summary not matching the code approved at pre‑authorisation.
Submission deadline
Claims filed outside the post‑discharge window, which no amount of clinical justification recovers.
Incomplete uploads
Missing progress notes, diagnostic reports, implant invoices, consent forms or required photographs.
Rate ceiling breach
Billing above the approved package rate, which triggers deduction rather than outright rejection.
Unanswered queries
Query windows are short. An unanswered query becomes a rejection by default.
What gets measured
The baseline we establish first
Before any corrective work, the assessment fixes a number to the problem. Most organisations know denials hurt but cannot say by how much, in which categories, or against what benchmark.
| Measure | What it tells you | Reference point |
|---|---|---|
| Denial rate | Share of claims rejected on first submission | Under 10% acceptable, under 5% strong |
| Clean claim rate | Claims submitted without error or omission | Above 95% |
| First‑pass resolution | Claims paid without rework or appeal | Above 90% |
| Days in AR | How long cash sits in unpaid claims | Under 50 days |
| Denial value by category | Which causes carry the most money, not just the most claims | Ranked, top causes first |
| Recovery rate on appeal | Whether denied claims are being worked at all | Measured against denials raised |
Reference points are widely used industry benchmarks and are indicative rather than regulatory. Realistic targets for a given organisation depend on payer mix, case mix and scheme participation, and are set as part of the assessment rather than assumed.
How we work
Assessment to corrective action
1️⃣
Baseline
Establish denial rate, clean claim rate, days in AR and first‑pass resolution from your own claims data.
2️⃣
Categorise
Group denials by cause and rank by value, so the work starts where the money is rather than where the volume is.
3️⃣
Root cause
Trace each significant category to the point in the process that produced it, and to the role that owns that point.
4️⃣
Correct
Redesign the step, set the documentation standard, train the staff who perform it, and re‑measure the category next cycle.
Engagement models
Ways organisations use this
Scope follows the assessment. Fees are quoted per engagement once the size and shape of the problem are known.
📊
Revenue Leakage Assessment
The starting point. A measured baseline and a ranked list of what is being lost and why.
- Denial rate and category analysis
- Days in AR and clean claim rate
- Sample file review across payers
- Pre‑authorisation and documentation check
- Written report with recoverable value ranked
🔧
Root Cause & Corrective Action
The fix. Structured RCA on the categories that carry the most value, with process changes and training.
- RCA per major denial category
- Process redesign at the failure point
- Documentation and pre‑auth standards
- Staff training by role
- CAPA tracker with owners and dates
🔁
Ongoing Review
Keeping it fixed. Periodic review so denial patterns do not quietly rebuild.
- Denial trend review each cycle
- Pre‑auth and documentation spot audits
- Refresher training as staff change
- Scheme rule and package updates tracked
- Monthly reporting to leadership
Who this suits
Organisations that get the most from it
High denial rate, unknown cause
Where rejections are visibly hurting cash flow but nobody can say which categories carry the value or where they originate.
Delayed TPA and scheme payments
Where claims are eventually paid but the cycle is long enough that working capital is permanently tied up in receivables.
No structured pre‑auth process
Where pre‑authorisation, documentation and claims follow‑up depend on individuals rather than a defined process, and results vary with who is on shift.
Common questions
Before you enquire
We already have a billing team. What does this add?
A billing team processes claims. This work asks why claims fail. The two are different: most denials are created upstream of billing — at registration, in pre-authorisation, or in clinical documentation — and no amount of resubmission fixes a cause that keeps recurring. We categorise denials, trace each category to its origin, and fix the process that produces them.
What denial rate should we be aiming for?
Below 10% is the commonly cited threshold, and well-run operations target under 5%. Clean claim rate above 95% and first-pass resolution above 90% are the companion measures. Where organisations sit against those numbers is usually the first thing the assessment establishes, because many have never measured it.
How long does the assessment take?
The on-site portion is typically short. The analysis depends on how your data is held: an organisation with a clean claims export can be assessed quickly, while one reconstructing history from registers takes longer. The output is the same — denial categories ranked by value, with a root cause and an owner against each.
Do you handle insurance, TPA and government schemes?
Yes. Private insurers and TPAs, and government schemes including PM-JAY, CGHS and ESIC. The failure patterns differ — scheme claims fail more often on package codes, submission windows and mandatory uploads, private claims more often on policy terms, pre-authorisation and documentation adequacy — so they are analysed separately.
Will you take over our claims processing?
No. This is corrective and preventive work: assessment, root cause analysis, process redesign, documentation standards and staff training, so your own team produces fewer denials. We do not operate as a billing vendor.
What does the organisation need to provide?
Claims and denial data for a recent period, access to the staff who handle registration, pre-authorisation, billing and claims follow-up, and sample files from denied cases. The more complete the denial data, the sharper the root cause analysis.
Find out what your denials are actually costing
The assessment produces a number, a ranked list of causes, and an owner against each. What you do with it is your decision.