Revenue cycle leaders are operating in a very different financial environment than they were just a few years ago. 

Margins remain tight, and operational expenses continue to rise. Labor costs are up, staffing challenges continue, and hospitals are under growing pressure to improve financial performance without adding more strain to already stretched teams. 

These pressures are compounded by the fact that a relatively small, yet valuable subset of claims is driving a disproportionate share of administrative workload.  

Complex claims, made up of motor vehicle accident (MVA), workers’ compensation (WC), and VA claims, typically account for just 3 to 5% of total claim volume, yet represent 15-30%+ of at–risk or recoverable revenue.  By nature, they are more complex, requiring significantly more effort to resolve, and tend to remain in A/R longer. In an environment already constrained by margin pressure and limited bandwidth, this creates a high-value problem that many hospitals are not equipped to fully capture on their own.  

 

What Makes Complex Claims Different 

Complex claims follow a different path than traditional commercial billing. 

Because these claims typically behind with unplanned events – auto accidents, workplace injuries, and other emergencies — coverage is often not fully established at the point of service. Critical details may be missing at registration and after discharge, multiple stakeholders can become involved, including patients, employers, insurers, and sometimes attorneys.  

Instead of moving through a relatively straightforward billing process, these claims often depend on investigation, payer identification, documentation review, follow-up, and coordination across several parties. In many cases, the real work begins after the patient leaves. 

And while they may feel like exceptions, they are anything but.   

• The U.S. experiences over 6 million police-reported motor vehicle crashes annually, many of which involve injuries requiring care.  
• Workers’ compensation systems process millions of claims each year across the country, and 
• the VA community care program continues to expand, increasing reliance on non-VA providers.  

These are routine occurrences, not edge cases—making their complexity a persistent and scalable challenge for hospitals. 

 

Where the Cost Shows Up 

The cost of complexity rarely appears in a single, visible metric. Instead, it surfaces across multiple areas of performance—often subtly at first, but with cumulative impact over time. 

 

    1. Increased Manual Work After Discharge 

For many complex claims, the real work begins after the patient leaves.  

Teams must identify the correct payers, gather information, and initiate claims. This often requires repeated outreach and coordination across multiple parties. 

At the same time, hospitals are managing rising labor costs and staffing constraints, increasing the cost of each manual interaction. 

 

    2. Reduced Operational Efficiency Due to Inconsistent Workflows 

Because these claims represent a small share of total volume, workflows are often less standardized or predictable, increasing the risk of human errors, such as: 

• Billing the wrong payer first 

• Dropping accounts to self-pay prematurely 

• Missing coordination-of-benefits opportunities 

At the same time, national data shows denial rates across all claims are approaching 15% in some cases, even for services that were preapproved. That baseline risk makes getting it right the first time even more critical, because errors directly translate into delayed or lost revenue.  

 

    3. Increasing Payer Friction 

Hospitals are seeing more documentation requests and greater scrutiny from payers. 

In auto and workers’ compensation, third-party bill review firms often create additional layers of negotiation and delay. Payment methodologies are not always transparent, making it harder to validate reimbursement. 

Taken together, these dynamics compound over time—driving higher administrative burden, longer reimbursement cycles, and increased risk to already constrained revenue. 

 

The True Cost of Complexity 

The cost of complexity adds up over time. Because these claims represent a small share of overall volume, they don’t always stand out in high-level reporting. But their impact shows up in places leaders care about most. 

It contributes to: 

• Longer A/R cycles 

• Higher cost to collect 

• Delayed or missed reimbursement 

• Lower margins  

The symptoms are often spread across metrics, making them harder to isolate at first, but over time, that pattern becomes too great to ignore. 

Beyond direct costs, one of the most overlooked impacts of complex claims is opportunity cost. 

Revenue cycle teams are already managing a wide range of priorities. When experienced staff are pulled into manual follow-up, payer research, and claim validation, that time is no longer available for other high-value work. 

That may mean less time for: 

• Denial prevention efforts  

• Clean claim improvement  

• Patient financial experience initiatives  

• Broader revenue cycle optimization work  

This tradeoff does not always appear in a dashboard, but it affects day-to-day performance. 

 

What Strong Performance Looks Like 

Organizations that manage these claims effectively bring structure to the process—identifying them earlier, applying consistent coordination-of-benefits rules, establishing clear workflows for follow-up and escalation, and actively managing aging accounts. 

Rather than treating complex claims as a niche issue or handling them reactively, leaders are asking more focused questions: 

• How much revenue is tied up in this claim set?  

• How long does it take to resolve these accounts?  

• What effect are these claims having on A/R and cash flow?  

• Where do delays or errors happen most often?  

• How much staff time is being consumed by manual work?  

That shift matters because it brings structure and visibility to an area that has often operated in the background.  As a result, these claims become more predictable and less disruptive to overall revenue cycle performance.