Prediction of Health Claims Denial for Revenue Cycle Management Firm

Created algorithm that process claims data before sending it to the payer and flags each claim for its probability of denial from payer

Solution

• Processed huge data of claims through the intelligent ML algorithm by random forest method and classified the claim into three categories: Fully Paid, Fully Denied, Partially Denied. 
• For the category of full denial and partial denial, the appropriate CARC (Claim Adjustment Reason Codes) were predicted to allow the users to understand the reasons for denial. 
• Our algorithm can interpret the denial codes and automate the  process to correct the claims and submit to the payers