What is Predictive Analytics for Denials?

Predictive Analytics for Denials is the application of advanced Artificial Intelligence (AI) and Machine Learning (ML) to analyze historical claims, payer behavior, and provider documentation patterns to forecast the probability that a specific claim will be denied before it is submitted.

This process moves RCM from a reactive model (fixing denials after they occur) to a proactive model (preventing denials altogether) by providing a measurable denial risk score for every claim.

Why Predictive Analytics is Critical for CFOs and Financial Leaders

Predictive analytics is key to optimizing cash flow and preventing revenue leakage at its source.

• True Denial Prevention: Instead of guessing or waiting for retrospective reports, finance leaders can implement immediate automated interventions on high-risk claims, directly boosting the First Pass Resolution Rate (FPRR).
• Strategic RCM Intervention: Analytics identify systemic weaknesses (e.g., a specific payer is suddenly denying all codes submitted by one physician). This intelligence allows RCM leaders to target training or automated logic changes where they will have the highest financial impact.
• Improved Cash Flow Predictability: By reducing the volume of unexpected denials, predictive analytics stabilizes the claims funnel, resulting in a more predictable flow of cash.

Key Use Cases: Applying Predictive Scores

Predictive scores drive automated actions within an Integrated RCM Platform:

• Intelligent Claim Scrubbing: A claim with a high denial risk score automatically receives a final, mandatory review by both the Claim Scrubber and a human analyst before being submitted.
• Automated Root Cause Triage: When a denial is predicted, the system uses the underlying data points to automatically route the claim back to the source of the error (e.g., CDI team for documentation issues, or Eligibility Verification for front-end issues).

Predictive Analytics vs. Retrospective Reporting

The difference is timing and actionability:

• Retrospective Reporting: Tells you why you were denied last month (historical data).
• Predictive Analytics: Tells you if you will be denied today, enabling immediate intervention.

Resources and Education

• Candid Health Product: Predictive Analytics /product/analytics
• Candid Health Blog: Denial Prevention Strategies /blog/denial-prevention