Denials, unpaid claims, and "insurance isn't paying"

Last month's unpaid claims list looks familiar. Same codes. Same payers. Same dollars still waiting.

A denial is the insurance company's refusal to pay that claim as sent. If the cause is never fixed, the next claim hits the same wall. We would name the top reasons, fix those at the source, and stop treating every return as a brand-new fire.

The clean claim percent looks healthy. Deposits still lag. The report and the bank disagree.

Clean claim rate only says the claim left without a rejection. It does not prove money landed. Claims can sit unpaid, ignored, or partially paid while that rate still looks fine. We would put deposits next to unpaid claims, not next to a percent that feels comforting.

Payroll and "where's my money?"

Payers feel slow. Your team feels busy. You cannot tell who owns the stall.

Separate the two. Did the claim leave complete and on time, and did someone work the answer when it came back? If those steps are solid and the payer still sits silent or wrong, that is on them. If claims leave late, incomplete, or unanswered, that is on billing. We would sort by cause before you blame the market or fire the vendor.

Billing company – hire, fire, or oversee?

You call. They say they have nothing. Your screen still shows submitted.

Not on file usually means their system never accepted that claim, or it arrived under a different member or date. Confirm the claim left your system, then check the middleman that carries claims (the clearinghouse) for a rejection or a dead end. We would chase the handoff, not resubmit blind.

You sent the claim weeks ago. No payment. No denial. Just silence.

Silence is still a status. Confirm they accepted the claim, then work a short chase list by age and dollar size. Call, portal, or written follow-up with a date you will check again. We would rather see a few quiet claims worked on purpose than a long list nobody touches.

A deposit you already counted gets clawed back. The bank feels smaller overnight.

A takeback (also called a recoupment) is money insurance paid, then took back after a review. Treat it as its own queue: what they say was wrong, whether you agree, and whether an appeal is worth it. Do not bury takebacks inside normal unpaid claims, or the pattern stays hidden.

The statement went out. The patient calls angry. You are not sure the balance belongs to them yet.

Before you collect, confirm insurance finished its part: paid, denied, or adjusted. A balance that still belongs with the payer should not land on the patient. We would clear the insurance step first, then collect what is truly theirs.

Patient collect, front desk, and eligibility

The unpaid list never shrinks. Working oldest-first feels busy and never ends.

Sort by cause and dollar size, not only by date. Fix the reasons that keep sending work back, then clear the high-dollar claims that share that reason. We would rather see fewer claims fixed for good than a daily treadmill that looks productive and stays the same length.

The history shows the same claim out again and again. Nobody can say why the eighteenth try would work.

Resubmitting a known dead claim burns time and hides the real problem. Put a stop rule in place so the team pauses when the same claim fails the same way. Fix the cause once, then send a corrected claim, not another copy of the broken one.

Visits happened. Claims should be out. You cannot find them between created and accepted.

Claims get stuck in plain places: not created, rejected by the clearinghouse, sitting unworked after a denial, or waiting on a missing note. Walk the short path from visit to accepted claim and name the step that stopped. We would fix that handoff before you assume the payer ate the money.

AR aging and money from visit to bank · Start here if you still need to name the first worry.