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Denials Reduction via Root-Cause Program
Normalized root causes, policy-tied appeals, and clear ownership reduced preventable denials and AR drag.
Context
- Denials data existed but lacked a normalized root-cause map; dashboards drifted across teams.
- Appeals were inconsistent, with limited re-use of successful narratives and evidence.
- Handoffs between billing and clinics blurred ownership and slowed fixes.
Approach
- Denial Pareto with preventable vs. unpreventable split; normalized root-cause taxonomy.
- Appeal templates linked to payer policy; evidence tiles and checklists for artifacts.
- Worklist rules for first-touch speed and high-dollar prioritization; SLA clocks.
- Definition locks for dashboard tiles to prevent metric drift.
- Pilot lanes stood up with weekly calibration and change control.
Measured Results
- Preventable denials −27% in 8 weeks.
- Appeal win rate +12.2 pts.
- Days in AR −8.5% with fewer re-touches.
- Ownership clarified via RACI; fewer ping-pong handoffs.
Lessons Learned
- Start with a code→cause map; it drives both prevention and appeals.
- Lock tile definitions or you’ll never compare apples to apples.
- Appeal exemplars reduce cycle time and raise win rates.
- Worklists need clocks and rules, not just filters.
Fewer denials, faster cash
Prevent what you can, win what you must—with clear owners and clocks.
