Revenue cycle leaders know that complex claims are a major drain on hospital and health system resources. Between intricate coding, payer-specific policies, and ever-changing regulations, even the most experienced billing teams can struggle to control denials.
Over 80% of complex claims require additional intervention to secure payment, costing organizations valuable time and revenue (Change Healthcare, 2023).
At Transcend Health, we help healthcare organizations recover lost revenue and prevent future denials with proven RCM strategies.
Here are the five most common reasons complex claims are denied — and how to avoid them.
1. Incomplete or Inaccurate Patient Information
Even small errors in patient demographics (such as misspelled names, wrong policy numbers, or outdated addresses) can trigger immediate claim rejections.
How to Avoid It:
- Implement strong front-end training for accurate patient intake.
- Build quality checks into your claims submission workflows.
- Collaborate closely with intake and billing teams to quickly identify and correct errors.
Pro Tip: Transcend Health’s RCM specialists integrate detailed claims scrubbing and review processes to catch critical errors early, significantly lowering first-pass denial rates.
2. Lack of Medical Necessity Documentation
Many complex claims, especially in specialties like cardiology, oncology, or orthopedics, are denied for “lack of medical necessity” if documentation is missing or incomplete.
How to Avoid It:
- Ensure providers link procedures directly to specific ICD-10-CM diagnosis codes.
- Strengthen clinical documentation improvement (CDI) programs.
- Use templates and prompts in EHRs to support documentation compliance.
Pro Tip: Working with Transcend Health’s CDI specialists ensures claims are backed by solid, defensible documentation.
3. Prior Authorization Failures
Missing, delayed, or improperly obtained prior authorizations are a major cause of denials, particularly for complex procedures, surgeries, and infusions.
How to Avoid It:
- Centralize and streamline the prior authorization workflow.
- Double-check authorization requirements by payer and procedure type.
Pro Tip: Our Prior Authorization Service reduces manual workloads and increases approval rates, so your staff can focus on patient care, not paperwork.
4. Coding Errors
Incorrect CPT, ICD-10, or HCPCS codes — even a single digit off — can derail a complex claim. Coding for bundled services, modifiers, or newer procedures adds further risk.
How to Avoid It:
- Conduct regular coding audits.
- Provide coders with ongoing training on the latest CMS updates.
- Leverage expert outsourced coding support during high-volume periods.
Pro Tip: Transcend Health’s certified coders specialize in complex specialties, ensuring accuracy and compliance with payer policies.
5. Missed Filing Deadlines
Payers have strict timelines for claim submission. Complex claims often involve multiple steps, and if any part of the process is delayed, you risk missing the timely filing window.
How to Avoid It:
- Set internal filing deadlines earlier than payer-mandated ones.
- Use specialized partners like Transcend Health to monitor aging claims and escalate as needed.
Pro Tip: We prioritize high-risk claims with tailored workflows to beat even the tightest payer deadlines.
Complex claims don’t have to mean complex headaches.
By proactively addressing these five issues, healthcare organizations can recover more revenue, reduce administrative costs, and improve patient satisfaction.
At Transcend Health, we specialize in complex claims management, prior authorization support, and coding solutions that get results — fast.
Are you ready to lower your denial rates and accelerate reimbursement?
Contact Transcend Health today for a custom revenue cycle assessment.