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Medicaid denial economics

HCRI 90-Day Medicaid Denial Cost Calculator

Find out what Medicaid denials may actually be costing your agency — in delayed revenue, write-offs, and staff rework.

What this calculator separatesConfirmed cost already realized from write-offs and rework — versus current denied-revenue exposure that may still be recovered.

Calculate Your 90-Day Exposure Explore HCRI Resources

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90-Day Medicaid Activity

Put real numbers around the denial problem.

Use the last 90 days of Medicaid claim activity. Best estimates are fine if an exact loaded labor cost is not readily available. Calculations run entirely in your browser. Your entries stay in your browser unless you choose to request an emailed report.

Total Medicaid claims submitted in the past 90 daysCount submitted Medicaid claims, including paid, pending, and denied claims.

Total Medicaid dollars billed in the past 90 days

Use gross Medicaid charges submitted during the same 90-day period.

Number of Medicaid claims deniedUse denied claim count for the same 90-day period.

Total dollar value of denied claims

Total Medicaid dollars associated with those denied claims.

Denied dollars subsequently recovered

Denied revenue later paid after correction, resubmission, appeal, or other recovery action.

Denied dollars written off

Denied Medicaid revenue the agency has already determined will not be collected.

Average staff hours per week spent working denialsInclude time spent diagnosing, correcting, resubmitting, appealing, escalating, and following up.

Average fully loaded hourly staff cost

Use wages plus payroll taxes and benefits if known. If not, enter your best estimate.

Optional · Keep and share your results

Want a copy of your 90-Day Medicaid Denial Cost Report?

Request a clean HCRI summary of your denial rates, outstanding denied revenue, write-offs, staff rework cost, 90-day denial exposure, annualized exposure estimate, and any denial-source breakdown you entered. HCRI will email the report to the address you provide.

Your current 90-day denial exposure and confirmed denial cost

Claim and dollar denial rates

Outstanding, recovered, and written-off denied revenue

Estimated staff rework cost

Largest denial source and ranked source breakdown, if entered

A short HCRI interpretation of what to look at next

Optional source analysis

Where are your denials coming from?

If you know the denied-dollar amount by source, add it below. This does not affect the main calculator and does not need to equal your total denied dollars for the calculator to work.

Authorization

Eligibility / payer

EVV

Documentation / service validation

Coding / modifiers

Submission / routing

Other

What the numbers do not tell you by themselves

The claim is often where the problem becomes visible — not where it began.

A denial may start much earlier in the revenue cycle: authorization, eligibility, payer assignment, EVV, documentation, service validation, coding, or claim routing.

Working a denial can recover revenue.

Understanding why it happened — and putting the right controls in place before the next claim — is what prevents the same problem from repeating.

HCRS™ · Home Care Revenue Specialist — Certified

Build the operating controls behind the numbers.

Home Care Revenue Specialist — Certified (HCRS) teaches Medicaid-funded home care revenue operations across the full revenue cycle — including authorization, service delivery, EVV, claim construction, adjudication, denials, payment, reconciliation, and operational controls.

HCRS was built by a team whose combined experience includes more than 5,000 home care agency implementations over the past decade.

For an agency, the question is not whether every denial can be eliminated.

The question is whether stronger revenue operations can prevent, identify, or recover enough avoidable revenue problems to justify the investment.

Why HCRI exists

There are thousands of people doing this work every day who learned it the hard way — through state manuals, payer calls, denials, portal changes, EVV problems and years of experience. I think that expertise deserves to be recognized as a profession.

Julio BareaFounder & Executive Director · Home Care Revenue Institute

Questions about the calculator or HCRS?

Talk to HCRI.

support@homecarerevenueinstitute.org