Denial management & resolution
A denial is two problems in one: money that hasn't been collected, and a process that produced a claim the payer wouldn't pay. Working only the first leaves you reworking the same denial forever. We work both.
A working loop, not a rework queue
Denial management has two halves. Recovery gets the money that is still recoverable. Prevention stops the same category arriving next month. Practices that only run the first half stay busy and stay flat.
Capture and categorise
Every denial is logged with its reason code, payer, provider, service, dollar value and date. Categorisation is what turns a pile of individual problems into a pattern you can act on.
Triage by recoverability
Not every denial is worth the same effort. We prioritise by whether it is correctable, appealable, time-sensitive and material — so effort goes where it returns something.
Correct or appeal
Data and coding issues are corrected and resubmitted. Medical-necessity and clinical determinations are appealed with the documentation the payer's criteria actually call for, within the appeal window.
Follow through to a decision
Appeals are tracked, escalated to the next level where warranted, and pursued until there is an outcome. An unanswered appeal is a write-off in slow motion.
Report the pattern
Recurring causes are surfaced to your practice with the specifics — which payer, which code, which step upstream produced it — so the fix lands where the problem starts.
Most denials are made upstream.
The denial appears in billing, but the cause is usually somewhere earlier — registration, verification, authorization or documentation. Fixing it in billing alone means fixing it repeatedly.
Full article on denial causesRegistration and eligibility
Wrong or outdated policy information, terminated coverage, coordination-of-benefits confusion, claims routed to the wrong payer entity. Correctable, preventable, and among the most common categories in practice.
Fix upstream: eligibility verification →Authorization
No authorization on file, authorization expired, units exhausted, or approval issued for a different code or level of care than the one billed. Frequently a tracking failure rather than a clinical one.
Fix upstream: prior authorization →Coding and modifiers
Missing or inappropriate modifiers, bundling and unbundling edits, diagnosis codes that don't support the procedure billed, unit counts inconsistent with the documented time or service.
Fix upstream: billing coordination →Medical necessity and documentation
The service was delivered and coded correctly, but the record as submitted doesn't meet the payer's published coverage criteria. These are appealable, and they are won or lost on documentation quality.
Timely filing
The claim was submitted after the payer's deadline. Almost never recoverable, almost always avoidable, and a direct symptom of unmonitored claims or unworked A/R.
Fix upstream: A/R follow-up →Duplicate and coordination issues
Claims flagged as duplicates after a resubmission, or denials arising because a secondary payer was billed before the primary adjudicated. Process issues with straightforward process answers.
Let's build a healthier revenue cycle.
Tell us where your revenue cycle is under pressure right now. We'll walk through what's happening, what we'd take on, and whether working together makes sense for your practice.