Claims & Denial Management Intelligence Dashboard

Riverside Health System — Revenue Cycle Performance Intelligence

Net Collection Rate
94.7%
-1.3% vs target
Initial Denial Rate
8.4%
-0.6% MoM
First-Pass Resolution
67.3%
+2.1% WoW
Appeal Overturn Rate
41.8%
-3.4% MoM
Days in AR (Denied)
47.2
+5.8 days
Write-Off Rate
4.9%
-0.3% MoM

Payer-Procedure Denial Matrix (Last 90 Days)

Cardiology
Orthopedic
Behavioral Health
Emergency
Surgery
Imaging
Medicare Adv.
6.2%
4.8%
7.3%
3.1%
5.4%
4.2%
Medicaid
9.8%
8.5%
12.7%
6.4%
7.9%
5.8%
BCBS
4.1%
3.8%
5.2%
2.4%
3.2%
3.0%
Aetna
5.6%
6.1%
7.8%
3.7%
4.9%
4.3%
UnitedHealthcare
3.4%
2.9%
5.1%
2.6%
3.3%
2.7%
Molina Healthcare
13.2%
14.6%
22.4%
10.1%
11.8%
8.2%
Cell color intensity = denial rate. Red cell (Molina Behavioral Health) triggered by Week 7 retroactive auth requirement.

Denial Root Cause (Pareto)

Appeal Overturn Rate by Category

Denial Trend Velocity (12-Week Time Series)

Week 7 spike: Molina retroactive auth requirement for Behavioral Health outpatient (+53% denial volume over 3 days).

Days in AR Distribution (Denied Claims)

Denial Value at Risk (VAR)

Total Denied Charges (90d)
$14.2M
Expected Recovery (FPRR + Appeals)
$9.8M
Value at Risk (Write-Off Exposure)
$4.4M
VAR % of Denied
31.0%

Denial Detail (Top 10 by Volume — Last 30 Days)

Payer Procedure Denial Reason Count Total $ Avg Days AR FPRR Appeal Rate Overturn %
Molina Healthcare Behavioral Health OP Missing Prior Auth 487 $1,243,800 62.3 12.4% 74.2% 28.1%
Medicaid Orthopedic Surgery Not Medically Necessary 312 $892,400 53.1 38.5% 52.6% 41.3%
Medicare Adv. Cardiology Procedure Duplicate Claim 284 $614,200 41.2 81.7% 14.1% 62.5%
Aetna Behavioral Health OP Missing Prior Auth 247 $521,300 48.7 44.9% 48.2% 38.9%
Molina Healthcare Imaging (MRI/CT) Missing Prior Auth 219 $478,900 56.4 31.5% 61.2% 35.7%
BCBS Emergency Services Coding Error 198 $403,600 38.2 72.2% 22.7% 55.6%
Medicaid Cardiology Procedure Eligibility Lapse 176 $387,200 67.8 18.2% 29.5% 8.5%
UnitedHealthcare Imaging (MRI/CT) Duplicate Claim 164 $341,800 35.6 88.4% 9.1% 70.0%

Clean Claim Rate (8 Weeks)

91.6%
Current Week

Authorization Gap Rate

7.3%
Missing Prior Auths

Payer Contract Compliance

96.8%
Rate Match Accuracy

Denial Velocity Heatmap Calendar (12 Weeks)

Wk 1
Wk 2
Wk 3
Wk 4
Wk 5
Wk 6
Wk 7
Wk 8
Wk 9
Wk 10
Wk 11
Wk 12
Mon
42
38
51
44
39
48
127
68
53
41
37
49
Tue
45
52
47
56
43
54
134
71
58
46
40
51
Wed
51
48
55
49
52
46
142
74
62
53
44
50
Thu
47
54
50
57
48
59
81
67
55
49
45
52
Fri
53
49
58
51
56
50
73
62
57
50
47
54
Daily denial count. Week 7 Mon-Wed: Molina retroactive auth spike (127-142 denials/day vs. baseline ~50).