The Patient Had Insurance. The Claim Was Denied. The Appeal Took Weeks.

A single encounter may involve Medicare as primary, a Medigap plan as secondary, and patient responsibility for the remainder. Each payer has different covered services, different modifier requirements, and different reimbursement rates. Line-by-line EOB reconciliation across thousands of encounters per month is where billing staff spend most of their time.

Insurance companies have accelerated automated claim review, resulting in more denials. Each denial requires root cause investigation: coding error, missing authorization, documentation gap, or eligibility issue. The correction and resubmission cycle consumes more staff hours than the original claim processing.

With higher deductibles and cost-sharing, providers collect approximately 30% of total revenue directly from patients. Collection rates average only 66%. Patients do not understand their bills, dispute charges they do not recognize, and delay payment on balances they were not expecting.