Staff Series – R2 M2: Claims & Denials
RCM FOUNDATION SERIES · ROUND 2
Module 2 of 3

Claims & Denials

Round 2 — Module 2 · How your work prevents rework
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Round 2 Progress
1
Why It Gets Measured
2
Claims & Denials
3
Getting Paid & Collections

Two Numbers, One Cause

Clean Claim Rate and Denial Rate are two sides of the same coin. A clean claim is one that goes out correctly and gets paid without a fight. A denial is a claim that comes back — and every denial means someone has to stop, research, correct, and resubmit it. That's rework, and rework is time no one has extra of.

Where These Numbers Come From

Clean Claim Rate

The percentage of claims accepted the first time, with no errors. Driven by accurate demographic entry, correct insurance details, and complete documentation before the claim ever leaves the building.

Denial Rate

The percentage of claims that come back unpaid. The most common causes are eligibility that wasn't checked at the visit, an authorization that expired or was never obtained, and coding that doesn't match the documentation.

Why This Matters to You

Every denial is a second trip. Someone has to go back, figure out what went wrong, fix it, and resend the claim — work that a few extra minutes upfront would have prevented entirely.

Where Denials Usually Start

Watch for these: insurance not re-verified at every visit (not just the first one), authorizations that expire mid-treatment, and documentation that doesn't fully support the codes billed. Catching these before submission is far easier than fixing them after a denial.

Check Your Understanding

1. What does a denied claim require that a clean claim doesn't?
Correct. Denials create rework that a clean claim never needed.
Not quite. A denial means someone has to research, fix, and resend the claim.
2. Which of these is a common, preventable cause of denials?
Correct. Expired authorizations are one of the most preventable causes of denials.
Not quite. Expired authorizations, not visit conditions, are a leading preventable cause.
3. Why should insurance be re-verified at every visit, not just the first one?
Correct. Coverage can change at any time, so checking only once isn't enough.
Not quite. Coverage can change between visits, which is why it needs re-checking each time.

Nice work — continue to Module 3.

Continue to Module 3
Continuity Practice Partners · Bend, Oregon
www.continuityrcm.com · info@continuityrcm.com