In the healthcare industry, insurance claim denials directly impact a provider's cash flow and bottom line. This project analyzes ₹25 Million in total billed hospital claims to uncover revenue leakage, track insurance payer performance, and pinpoint the root causes of claim denials.
By transforming raw billing and medical coding data into actionable visual insights, this interactive dashboard helps healthcare administrators optimize Revenue Cycle Management (RCM), reduce denial rates, and accelerate reimbursement.
- Data Visualization: Tableau Public
- Domain Knowledge: Healthcare Revenue Cycle Management (RCM), Medical Coding, Insurance Payer Guidelines, Claim Denial Management.
- Total Billed Amount: ₹25,000,000 (Total revenue submitted to insurance payers)
- Total Denied Revenue: ₹3,000,000 (Revenue frozen due to rejected claims)
- Overall Denial Rate: 22.40% (Industry benchmark is typically under 10%, indicating a critical need for process improvement)
- Orthopedics is the single largest contributor to revenue leakage, accounting for over ₹2.1 Million of the total denied revenue.
- Cardiology follows as the second highest with ₹961K in denials, while Neurology stands at ₹279K.
- Actionable Insight: Focused training on clinical documentation improvement (CDI) and specific coding guidelines should be prioritized for the Orthopedics billing team.
- BlueCross BlueShield has both the highest financial volume of denials (exceeding ₹750K) and the highest overall denial rate at 25.66%.
- Cigna (23.72%) and Medicare (22.07%) also track above the average line.
- UnitedHealthcare represents the most efficient pipeline with the lowest denial rate at 19.63%.
The dashboard tracks top denial reasons using industry-standard remark codes, highlighting:
- Claim Lacks Information: Missing critical patient data or modifier codes at submission.
- Medical Necessity Not Met: Lack of sufficient clinical documentation to justify the procedure.
- Expenses Incurred After Coverage Terminated / Maximum Benefits Exceeded.
- Implement Front-End Edits: Address the "Claim Lacks Information" denials by creating automated claim-scrubbing rules before claims leave the hospital system.
- Payer-Specific Audits: Initiate a targeted review of BlueCross BlueShield submissions to identify why their denial rate is disproportionately high (25.66%).
- Pre-Authorization Workflows: Standardize pre-authorization checks for high-volume Orthopedic procedures to mitigate "Medical Necessity" denials.