Denial Management & Appeals
Shrink denials and boost overturns with payer-specific playbooks, standardized appeals, and dashboards that reveal root causes—so issues don’t return.
When Denials Work Best
- Denials trending up or clustered in a few payer categories
- High rework & write-offs due to preventable front-end errors
- Appeals lack standardization, timelines, or evidence packaging
- You want measurable lift before expanding to full-service billing
Common Denial Categories
- Eligibility & Coverage · COB · Authorization/Referral
- Coding & Modifiers · NCCI · LCD/NCD · Bundling/Unbundling
- Timely Filing · Medical Necessity · Documentation Insufficiency
- Duplicate · Experimental/Investigational · Place of Service
- Underpayments & Contract Variance (rate issues)
Quality
QA & Evidence
- Defect taxonomy tied to payer reason codes & clinic SOP versions
- AQL sampling per denial reason with calibration & scorecards
- Coaching notes linked to defects; recurrence watchlists
- Evidence packs (notes, auth, medical records) embedded in appeals
Coverage
Appeals & SLAs
- Appeals TAT by severity (standard/expedited) with checkpoints
- Surge buffers for seasonal volumes or payer backlog events
- Cross-training across top 5 denial categories per specialty
- Change windows & rollback procedures for payer rule updates
Visibility
Dashboards
- Clean Claim Rate, First-Pass Denial Rate, Rework %
- Top denial reasons (Pareto), appeal yield, overturn rate
- TATs: rejection rework, appeal submission, payer response
- Feedback loops to coding/front desk; training completion
Upgrade Paths
Keep Denials service; expand to top-10 payers/categories
Hybrid: Carenox runs appeals + clinic runs submissions
Migrate lanes to Full-Service Billing (end-to-end with SLAs)
Compare RCM Lanes
| Dimension | Claims Submission | Denial Mgmt (This) | Accounts Receivable |
|---|
| Focus | Clean claims, payer edits, rejections | Appeals & overturns; root causes | Collections & underpayments |
| Quality | Scrub rules + AQL checks | Defect taxonomy + evidence packs | Worklists, contact logs, QA notes |
| Dashboards | Clean claim %, rejection TAT | Top reasons, appeal yield, TAT | AR aging, recovery, underpayments |
Cut denials. Collect faster.
We’ll analyze your top denial reasons and launch payer-specific appeals with clear SLAs.
