Medical Billing

Submitted is not paid.

What breaks here

The most common failure in medical billing is not a rejected claim. It is a claim that was submitted correctly, accepted quietly, and then never looked at again. It sits in the payer's system, ages past thirty days, past sixty, and eventually surfaces on an A/R report as a number nobody can explain.

The second failure is the clearinghouse reject that lands in a queue on a Friday. Nobody owns the queue. By the time someone works it, the claim has lost two weeks of its filing window for no reason other than that it was waiting.

What we do about it

Claims are scrubbed against payer-specific edits before they leave our system, not against generic rules. A Medicare Advantage plan and a commercial PPO reject for different things, and the edit set reflects that.

Every submitted claim carries an expected response date. When the payer misses it, the claim surfaces for follow-up automatically rather than waiting for someone to notice it on an aging report. Clearinghouse rejections are corrected the same business day.