Denial Brain

Determine the chance of healthcare claims denials.

While the healthcare industry has been trying to fix the claims denial problem for the past 20 years with various revenue cycle management solutions, the problem has persisted and the numbers continue to climb, presenting significant fiscal challenges to providers.

The problem

Of an estimated $3 trillion in claims submitted by hospitals in 2016, an estimated 9% of charges ($262 billion) were initially denied. For the typical health system, as much as 3.3% of Net Patient Revenue, an average of $4.9 million per hospital, was put at risk due to these denials. The industry average for claims in A/R is approximately 63 days. In larger providers, A/R days can run as high as 97 days on average. Total days in A/R is creating a cash flow burden on providers. Additionally, of the $262 billion in claims originally denied in in 2016, only 63% was recovered, putting pressure on net income.

What the problem looks like

Claims denials by region

Top reasons for claims denials

AI solution. developed a white box, intelligent system of engagement capable of analyzing individual claims to cluster them with similar claims in order deliver a percentage chance of denial (e.g. 67% chance of denial). Once grouped, the system compares the individual claim to billions of similar claims to determine trends in the various groups (e.g. payer, diagnosis, coding, service not covered, additional documentation, untimely filing) the final adjudication of the larger set of claims in order to render a chance of denial of the original claim. Once the chance of denial is determined, the system will explain the results and make improvement suggestions resulting in a lower chance of payer denial.


70% reduction in claims denials 45% reduction in A/R days