Revenue Cycle Management
Customized, end-to-end RCM for practices of every size, from claims review to denial recovery.
Core RCM
Turn Claim Denials Into Actionable Revenue Insights
Denials are not only payment problems; they show where the revenue cycle is breaking. Our team is well-versed in denial management strategies and works diligently to identify the root causes of denials, recover revenue and prevent repeats.
At a glance
- The problem
- Unworked denials, missed appeal deadlines and the same denials repeating every month.
- Measured by
- Denial rate
- Appeal success rate
- Preventable denials
- Denial turnaround time
- First step
- A free RCM assessment of your current workflow
Denial Management
What we do
- Denial categorization
- Appeals
- Payer follow-up
- Root-cause analysis
- Trend reporting
- Preventable-denial identification
- Escalation workflows
Process
How we work a denial
- 01Capture
- 02Categorize
- 03Prioritize
- 04Appeal
- 05Fix root cause
- 06Report
Denial Explorer
What Is Behind Your Denials?
Choose a denial code from your remittance to see what it usually means, why it happens and how we fix and prevent it.
Missing or invalid information
Usually recoverableThe claim is missing information the payer needs, or some of it is invalid. A remark code on the remittance says exactly what.
Common causes
- Missing or invalid NPI, taxonomy or referring provider
- Incomplete patient or subscriber details
- Missing modifiers, units or service dates
How we fix it
- Read the remark code to find the missing item
- Correct the claim and resubmit it electronically
- Track the corrected claim until it pays
How to prevent it
- Claim scrubber edits for the fields each payer requires
- A registration checklist at the front desk
Example · illustrative
An office visit claim is sent without the referring provider's NPI and comes back unpaid.
Authorization or precertification missing
Sometimes recoverableThe payer required approval before the service, and the claim shows none on file.
Common causes
- Authorization never requested for a service that needs one
- Authorization expired or covered fewer visits than were billed
- Authorization number left off the claim
How we fix it
- Check the payer portal for an approval that was not attached
- Request a retro-authorization where the payer allows it
- Appeal with notes showing the service was urgent or medically necessary
How to prevent it
- Check authorization requirements when the visit is scheduled
- Track approved visit counts and end dates
Example · illustrative
A course of physical therapy runs past the 12 approved visits; visits 13 to 15 are denied.
Not medically necessary
Sometimes recoverableThe payer does not consider the service medically necessary for the diagnosis billed.
Common causes
- The diagnosis code does not support the service under the payer's policy
- Documentation does not show why the service was needed
- Frequency limits exceeded
How we fix it
- Compare the claim with the payer's coverage policy
- Correct the coding if the documentation supports a different diagnosis
- Appeal with clinical notes that show necessity
How to prevent it
- Check coverage policies for high-cost or frequently denied services
- Get signed advance beneficiary notices where they apply
Example · illustrative
A routine vitamin D test is billed with a diagnosis the payer's policy does not cover.
Filing deadline passed
Rarely recoverableThe claim reached the payer after its timely filing limit.
Common causes
- Claims held in a work queue or rejected without follow-up
- Claims sent to the wrong payer first
- Late charge entry
How we fix it
- Look for proof of timely filing, such as a clearinghouse acceptance report
- Appeal with that proof if the original claim was on time
How to prevent it
- Work clearinghouse rejections every day
- Watch each payer's filing limit in A/R reports
Example · illustrative
A claim rejected at the clearinghouse sits unnoticed for four months and misses a 90-day limit.
Bundled into another service
Sometimes recoverableThe payer considers this service part of another one already paid on the same claim or date.
Common causes
- A procedure billed alongside a related one it is normally bundled with
- A missing or wrong modifier (for example 25 or 59)
- Global surgery period overlaps
How we fix it
- Check the bundling edits for the code pair
- Add the right modifier when documentation supports a separate service, then resubmit
- Write off correctly bundled services
How to prevent it
- Coding edits that flag common code pairs before submission
- Coder training on modifier use
Example · illustrative
A minor procedure and an office visit on the same day are billed without modifier 25 on the visit.
Diagnosis does not match the procedure
Usually recoverableThe diagnosis code on the claim does not support the procedure billed.
Common causes
- Diagnosis codes in the wrong order or linked to the wrong line
- An unspecified or outdated diagnosis code
- Coding from an incomplete note
How we fix it
- Review the documentation and correct the diagnosis link or code
- Resubmit the corrected claim
How to prevent it
- Coding review for services with frequent mismatches
- Code to the highest specificity the note supports
Example · illustrative
A knee X-ray is linked to a diagnosis for the opposite knee.
Coverage ended before the service
Sometimes recoverableThe patient's coverage with this payer had ended on the date of service.
Common causes
- Eligibility not checked before the visit
- The patient changed plans or employers
- Coverage lapsed for nonpayment
How we fix it
- Re-verify eligibility and find the active payer
- Bill the correct payer, or the patient if no coverage applies
How to prevent it
- Check eligibility before every visit, not only the first
- Ask about insurance changes at check-in
Example · illustrative
A patient changes jobs in March; an April visit is billed to the old employer's plan.
Duplicate claim
Rarely recoverableThe payer has already received a claim for the same patient, service and date.
Common causes
- A claim resubmitted while the original was still processing
- A corrected claim sent as new instead of as a replacement
- Duplicate charge entry
How we fix it
- Check the status of the original claim before doing anything else
- Send corrections as replacement claims with the right frequency code
How to prevent it
- Check claim status before resubmitting
- Duplicate-charge checks at charge entry
Example · illustrative
A claim with no response after 20 days is sent again while the first one is still in review.
Codes are standard Claim Adjustment Reason Codes with the CO (contractual obligation) group. Examples are illustrative.
Measurement
KPIs we track
Agreed at the start and reviewed with you every month.
Monthly KPI reviewTracked from day one
- Denial rate
- Appeal success rate
- Preventable denials
- Denial turnaround time
Questions
Denial Management FAQ
What are the most common denial reasons?
Missing or incorrect patient information, eligibility and coverage problems, missing prior authorizations, coding errors, duplicate claims and missed filing deadlines. Most are preventable with checks before submission.
How fast are appeals filed?
Appeals are prioritized by deadline and value, so time-sensitive and high-dollar denials are worked first.
Can you work our existing denial backlog?
Yes. We categorize the backlog, appeal claims still within their filing limits first and report what can still be recovered.
Related services
Often paired with
Next step
Let's Find the Opportunities in Your Revenue Cycle
Tell us about your practice and current revenue-cycle challenges. Our team will help identify practical next steps.