The Compliance Challenge: A Universal Pain Point

Policy Volatility Creates Operational Risk

Healthcare organizations today face an unprecedented level of policy complexity and change. Payers update their policies multiple times per year, often with subtle changes that can have significant impact on claim approval rates. These modifications can range from minor adjustments in documentation requirements to major overhauls of coverage criteria, and the frequency of these changes creates a moving target that's difficult to track manually.

Providers must also navigate requirements, timelines, and procedures across numerous payers. The billing and reimbursement process demands compliance with varying rules, coverage policies, and reimbursement rates that are payer-specific, creating additional challenges in claim development, submission, and the appeals process⁴. A procedure that is approved (either on first submission or following appeal) by one payer might be denied by another due to different coverage policies or documentation standards.

Financial Stakes

The financial implications of compliance failures are staggering. Each denied claim represents additional time spent on rework, from researching the denial reason to gathering additional documentation, resubmitting claims, and managing appeals. The cumulative effect is enormous: $20 billion was spent in 2022 on delays and denials across all payer types⁵. This figure represents not just direct costs but also the opportunity cost of staff time diverted from productive activities to managing preventable compliance issues.

RCM-Specific Challenges

RCM professionals face a particularly complex set of compliance challenges that extend beyond basic claim submission yet can lead to immediate revenue impacts. Violations of fraud and abuse law represent serious risks that can result in significant penalties and reputational damage. HIPAA breaches continue to be a concern, particularly as healthcare organizations adopt new technologies and workflows. Medicare and Medicaid payers often have different requirements and audit procedures compared to commercial payers. Yet, RCM professionals must navigate all these complexities on tight filing deadlines or risk disrupting cash flow⁶.

Why Traditional Compliance Tracking Falls Short

Fragmented Monitoring Systems

Without comprehensive solutions like the Payer Compliance Dashboard, healthcare organizations may continue to rely on fragmented monitoring systems that require manual tracking methods and individual payer website monitoring. Staff members are often assigned to check specific payer websites regularly, maintaining spreadsheets or other manual documentation systems to track policy changes. This approach is not only time-consuming but also prone to human error and inconsistency.

These fragmented approaches create information silos, where different departments or individuals may have access to different pieces of compliance information, but no one has a complete picture. Communication delays and manual tracking efforts only compound the problem, as important policy changes may not be communicated quickly or effectively across the organization⁷.

Distilling the Unmet Need in Compliance Tracking

The fundamental challenge is that payer contracts and policies change frequently, yet it's critically important to stay on top of these changes to avoid claim denials. Administrative errors include lack of patient eligibility verification, incomplete claim submission, and appeal timeline errors, all of which lead to claim denials and rejections⁸ . This can even result in dangerous and expensive delays in patient care, creating both financial and clinical risks for stand-alone and integrated healthcare organizations⁹.

How the Payer Compliance Dashboard Transforms Compliance Management

Curated Policy Intelligence

The Payer Compliance Dashboard from Policy Reporter by Valeris revolutionizes compliance management by providing pre-defined answers to compliance questions that healthcare organizations encounter daily. This curated approach eliminates the countless hours typically spent on manual research and reduces reliance on manual tracking tools that are prone to errors and gaps. By ensuring access to accurate, up-to-date information, the dashboard transforms compliance from a reactive process to a proactive strategic advantage.

Specialty-Specific and Customizable Views

One of the dashboard's most powerful features is its ability to provide curated views with filtering capabilities by payer, plan type, and state . For providers, this means the ability to focus on the payers that are most relevant to their practice, reducing information overload and increasing the relevance of compliance alerts and updates. And for RCM professionals, these customizable views enable them to prioritize and focus on high-risk areas that experience frequent denials. This targeted approach allows for more efficient resource allocation and more effective intervention strategies.

Advanced Analytics and Comparative Analysis

The dashboard's analytical capabilities allow users to compare rules across different payers, identifying outliers that might otherwise go unnoticed. This comparative analysis helps organizations understand why certain claims might be approved by one payer but denied by another, enabling more strategic approaches to claim submission and appeals management. By identifying these patterns early, organizations can minimize costly resubmissions and improve their overall approval rates.

Continuous Policy Tracking

Perhaps most importantly, the dashboard provides ongoing monitoring without requiring manual surveillance. Policy changes are automatically tracked and updated rows are highlighted, ensuring that teams stay informed about updates that could impact their operations. This ongoing monitoring eliminates the risk of missing critical policy changes and provides peace of mind that compliance information is always current.

Powerful Dashboard Visualizations

While frontline RCM teams may rely more on claim-level details in their daily workflows, the visualizations within the Inpatient Claims Payer Compliance Dashboard offer critical value to RCM managers and leadership. For managers, these insights enable strategic prioritization of claim submission and appeal workflows. For example, by quickly identifying which payers in a state have the strictest or shortest filing deadlines, teams can adjust processes to focus on high-risk claims first.

Using the visualization tool within the Inpatient Claims Payer Compliance Dashboard, our team was able to draw some interesting data insights. Did you know that:

Timely filing (participating providers) - Among the 18 million lives covered by Commercial payers in the state of Texas, claim filing must occur within:

• 90 days (1 million lives)
• 95 days (1 million lives)
• 365 days (10 million lives)
• Per provider agreement (3 million lives)
• Unspecified (3 million lives)

Appeal/dispute (participating providers) - among the 7 million lives covered by Medicare FFS & Medicare Advantage payers in the state of California, appeal/dispute must be filed within:

• 90 days (24,000 lives)
• 120 days (4 million lives)
• 180 days (132,000 lives)
• 365 days (2 million lives)
• 18 months (125,000 lives)
• Per provider agreement (37,0000 lives)

Prompt payment - among the 3 million lives covered by Managed Medicaid & Medicaid FFS payers in the state of Florida, prompt payment is specified as within:

• 15-20 days (85,000 lives)
• 20 days (135,000 lives)
• 20-40 days (2 million lives)
• 90 days (522,000 lives)
• Per provider agreement (148,000 lives)
• Unspecified (259,000 lives)

For RCM leaders, insights such as these serve as a powerful communication tool. By surfacing shifts in payer behavior over time, such as tightening appeal deadlines or increasing documentation requirements, leaders can demonstrate operational awareness and proactive planning in conversations with executives and finance leadership. The ability to aggregate complex compliance data into clear, visual summaries also supports performance reporting and resource justification at the CFO level.

Two Options to Choose From

With the Payer Compliance Dashboard, your RCM team no longer needs to dig through countless payer webpages to gather information. Choose from two options:

50-State Inpatient Claims dashboard:

• Curated with the critical data points your team needs to manage payers across all states.
• See up-to-date filing requirements, peer-to-peer review guidelines, readmission policies, and appeals and dispute processes all in one place.

Customized Payer Compliance Dashboard:

• Data tailored to your health system’s specific focus such as outpatient claims, multiple procedure reduction, clinical trial compliance, and more.
• Track policies across commercial, Medicare, and Medicaid payers, with direct links to full documents and curated data fields.

Practical Applications for RCM

The Payer Compliance Dashboard offers specific benefits for different roles within RCM.

• Contract managers can better understand and negotiate complex claims payment rules by having comprehensive access to payer policies and requirements. This knowledge enables more effective contract negotiations and helps to identify potential issues before they become costly problems.

• Physician advisors and utilization review professionals gain access to peer-to-peer guidelines, helping align payer and provider goals more effectively. This alignment reduces the likelihood of disputes and improves the efficiency of utilization review processes.

• Billing staff and practice managers benefit from proactive alerting and an easy-to-use interface that makes compliance monitoring less burdensome and more effective.

• Denials and appeals management teams can use the dashboard to both investigate and preempt future denials by tracking policy changes that might affect pending claims and reviewing historical versions of payer policies. This enables a proactive approach allowing teams to address potential issues before claims are submitted, reducing denial rates and improving cash flow.

Best Practices for Dashboard Implementation

Optimize Processes

Organizations should train staff on how to use the Payer Compliance Dashboard to prioritize denials management workflows effectively. For example, users can prioritize payers with the shortest submission deadlines to prevent issues with filing timelines. When deeper analysis is needed, teams should know how to use the broader Policy Reporter by Valeris platform to access source documents, their historical versions, and our side-by-side document comparison tool to conduct more detailed research.

Create Accountability Structures

Effective implementation requires clearly defined monitoring responsibilities, with specific individuals accountable for tracking policy changes in their areas of expertise. Organizations should set implementation speed standards to ensure that policy changes are acted upon quickly and create documentation protocols to maintain records of compliance activities and decisions.

Establish Clear Workflows

Successful implementation of the Payer Compliance Dashboard requires establishing clear workflows that integrate compliance monitoring into daily operations. This includes frequent reviews of policy updates and alerts, reviews for health care practice process improvement opportunities, and compliance meetings for strategic planning and assessment of trends.

Measure Impact

To demonstrate the value of the dashboard implementation, organizations should track key metrics including reduction in denial rates, time-savings on policy research, fewer non-recoverable denials such as missing submission deadlines, lower administrative burden associated with locating policies as well as onboarding new team members, and decreases in appeals and resubmission volume. These metrics provide tangible evidence of the dashboard's impact on operational efficiency and financial performance.

Conclusion

Healthcare organizations face unprecedented challenges from increasing administrative burden and denial rates, and a complex, ever-evolving compliance landscape. The statistics bear this out: three in four healthcare staff told Experian Health they experienced increased denials between 2022-2024¹. And analysis by Kodiak RCA (formerly Crow healthcare consulting) found that receivables aged over 90 days has grown dramatically across the industry (Medicare Advantage from 19% to 36% and commercial from 27% to 36%), a change that has been driven by increased initial claim denials¹⁰. Managing these challenges manually has become an incredibly burdensome task that diverts valuable resources from patient care and other productive activities.

The solution lies in adopting proactive tools that enable organizations to stay ahead of policy changes rather than react to compliance failures after they occur. The Payer Compliance Dashboard from Policy Reporter by Valeris represents a strategic investment that benefits both healthcare providers and RCM professionals and enables a proactive approach allowing teams to address potential issues before claims are submitted, reducing denial rates and improving cash flow.

"This is great... We've taken a process that can takes week to put together for one market and now in a matter of seconds we can quickly validate across the board!" -Vice President, Managed Care Operations at one of the nation's largest Health Systems

Organizations should evaluate their current compliance processes and honestly assess whether their existing tools are adequate for today's complex healthcare environment. The question isn't whether you need compliance tools, but whether the ones you've invested in are working for your team. Better tools help reduce claim denials, resulting in faster payments, fewer prolonged appeals, and overall improved financial health that ultimately supports better patient care and organizational sustainability.

Take control of your compliance strategy and protect your bottom line. Connect with our team to see how the Payer Compliance Dashboard from Policy Reporter by Valeris can help you reduce risk, stay ahead of payer requirements, and accelerate your revenue cycle.

References

1. Vogel, Susanna. "Providers say claims denials are increasing: survey." Healthcare Dive, September 25, 2024, https://www.healthcaredive.com/news/provider-claims-denials-increase-2024-experian-health-study/727999/
2. LaPointe, Jacqueline. "Breaking down claim denial rates by healthcare payer." TechTarget, January 9, 2025, https://www.techtarget.com/revcyclemanagement/feature/Breaking-down-claim-denial-rates-by-healthcare-payer
3. “Payer Compliance Dashboard." Policy Reporter by Valeris, 2025, https://www.policyreporter.com/solutions/payer-compliance-dashboard/
4. "Revenue cycle management (RCM) 101: What healthcare businesses need to know." Stripe, February 14, 2025, https://stripe.com/resources/more/revenue-cycle-management-101-what-businesses-need-to-know
5. Muoio, Dave. "Providers 'wasted' $10.6B in 2022 overturning claims denials, survey finds." Fierce Healthcare, March 22, 2024, https://www.fiercehealthcare.com/providers/providers-wasted-106b-2022-overturning-claims-denials-survey-finds
6. Medical Economics Staff. "Revenue cycle management compliance risks, explained." Medical Economics, February 20, 2025, https://www.medicaleconomics.com/view/revenue-cycle-management-compliance-risks-explained
7. Eastwood, Brian. "How Do Data Silos Impede Patient Care and Provider Efficiency?" HealthTech, April 22, 2025, https://healthtechmagazine.net/article/2025/04/how-do-data-silos-impede-patient-care-and-provider-efficiency
8. “Administrative denial examples.” PCH Global, 2025, https://pchhealth.global/glossary/administrative-denial
9. "Payer Denial Tactics — How to Confront a $20 Billion Problem." American Hospital Association, 2025, https://www.aha.org/aha-center-health-innovation-market-scan/2024-04-02-payer-denial-tactics-how-confront-20-billion-problem
10. Muoio, Dave. “Payers' increasing claims denials, delays 'wreaking havoc' on provider revenue cycles," Fierce Healthcare, December 14, 2023, https://www.fiercehealthcare.com/finance/payers-increasing-claims-denials-delays-wreaking-havoc-provider-revenue-cycles