Part of our billing service
Denial Management Services for Private Practices
Medtransic works every denied claim for the practices we bill for: we find why it was denied, correct and resubmit it or appeal it, and fix what caused it so the same denial stops coming back. Denial work is part of our billing at 4-8% of collections, and you can see each claim's status in your client portal.
- Date of service
- 03-14
- Payer
- Medicare Advantage
- Service
- Diagnostic imaging
- Billed
- $2,418.60
Illustrative sample
Key takeaways
- 01Systematic appeals process built to overturn denied claims across all payer types and specialties.
- 02Root-cause analytics surface recurring denial patterns before they cost you revenue.
- 03Payer-specific appeal templates built from real adjudication data - not generic letters.
- 04Prevention workflows target the root causes that keep denials recurring.
Common Problems in Denial Management
Claim denials drain revenue and resources from healthcare practices. These common challenges impact financial performance.
Denials Are Coming In Faster Than You Can Fight Them
When a big share of your claims bounce on the first try, the pile of rework grows faster than your team can clear it. Denials aren't patient: every payer sets a window for appeals, and a denial that sits in the queue too long ages past the point where anyone can fight it. Past that line, being right no longer matters - the money is gone on a technicality.
Impact: Costly rework processes and delayed revenue impact cash flow
Denied Claims Are Quietly Falling Through the Cracks
Denials arrive scattered across payer portals, remittance files, and mailed letters, and without one system that captures every single one, some simply never get logged. A denial nobody logged is a denial nobody works. Practices routinely discover, when someone finally reconciles billed against paid, that a meaningful slice of their revenue vanished this way - not disputed, not appealed, just forgotten.
Impact: Unworked denials mean lost revenue that can never be recovered
Weak Appeals Get Rejected and Waste the Effort
An appeal is an argument, and payers reject weak ones. A generic letter that restates the claim without addressing the specific denial reason, in the format that specific payer requires, with the documentation that payer wants attached, usually loses - which means your team burned an hour of work and still didn't recover the money. Losing appeals also teaches staff that appealing is pointless, so fewer denials get fought at all.
Impact: Low appeal success rates leave money on the table
The Same Denials Keep Happening Over and Over
Most denial volume isn't random - it's a handful of recurring causes generating the same denial month after month: a registration field entered wrong, a service billed before verification, a payer rule nobody flagged. If all your team ever does is fix individual denials, the leak refills as fast as you bail. The pattern only stops when someone traces denials back to their cause and fixes the process.
Impact: Continuous cycle of preventable denials drains resources
Fighting Denials Is Burning Out Your Staff
Denial rework is grinding, thankless work: hold queues, resubmissions, letters that get rejected on formatting. Staff stuck in that loop full-time make more errors, resent the work, and eventually leave - taking their hard-won payer knowledge with them. And because they're always reacting, nobody ever has time for the prevention work that would shrink the pile.
Impact: High administrative costs and staff burnout from repetitive work
Money You Earned Is Being Written Off
Of the roughly 85 million in-network claims denied by HealthCare.gov marketplace insurers in 2024, consumers appealed fewer than 1% - and insurers upheld only 66% of the appeals they did receive, meaning about a third were overturned (KFF analysis of CMS Transparency in Coverage data). Every unworked denial becomes a write-off, and a write-off is care your clinicians delivered, documented, and billed, converted to zero. It's usually the largest recoverable pool of money in a struggling revenue cycle.
Impact: Permanent revenue loss from abandoned denied claims
How We Approach Denial Management End to End
Our team pairs specialty expertise with data-driven systems to close revenue gaps fast.
We See Every Denial and Why It Happened
Step one is simply seeing everything. Every denial from every payer gets logged and categorized in one tracked worklist as it arrives - no portal left unchecked, no paper letter lost in a stack. Each one is categorized by what actually caused it, so instead of a chaotic pile you get a clear picture: these five causes are producing most of your denials, and here's what each is costing you.
Every denial tracked across all payers / Grouped by reason so patterns stand out / Root causes identified, not just symptoms / Trends flagged before they cost you more
Appeals Built to Actually Win
An appeal that wins answers the denial's actual reason, in the payer's required format, with the exact supporting records attached. Our appeal writers know what each of your payers responds to - which arguments work, which clinical documentation to pull, when to cite the payer's own published policy back at them - and when a first-level appeal is wrongly denied, we escalate to the next review level instead of accepting the loss.
Professionally written appeals / Tailored to each payer's requirements / Backed by the right supporting records / Escalated further when a first appeal fails
Stopping Denials Before They Happen
Winning appeals recovers money once; fixing causes recovers it every month afterward. When the tracking data shows a recurring cause - coverage not verified before visits, authorizations missed for certain procedures, a claim error repeating from one workflow - we fix that upstream process, not just the individual claims. Over time this is what actually shrinks your denial volume rather than just managing it.
Claims checked for errors before they go out / Coverage verified before the visit / Accuracy reviewed upfront / Authorizations tracked and managed
Nothing Slips Past a Deadline
Every denial carries a countdown - the payer's appeal deadline - and our worklists are built around it. Denials are worked in priority order by deadline and dollar value, so the claim expiring soonest and worth the most gets attention first, and no recoverable dollar is lost because a deadline passed while the claim sat in someone's inbox. Every action taken is logged, so you can see exactly what happened on any claim.
Denials worked in priority order / Deadlines tracked so claims don't expire / Less manual chasing for your team / A full record of every action taken
What's Included in Denial Management, in Detail
Every component managed with precision and expertise.
Denial Analysis & Reporting
Track, categorize, and analyze all denials to identify trends, opportunities, and areas for improvement.
Denial reason categorization / Payer-specific analysis / Trend identification / Custom reporting dashboards
Appeals & Reconsiderations
Professional appeal letter preparation with complete supporting documentation for maximum overturn success.
Expert appeal writing / Documentation gathering / Payer-specific strategies / Multi-level appeals
Root Cause Resolution
Identify systemic issues causing denials and implement corrective actions to prevent recurrence.
Pattern recognition / Process improvement / Staff training / Workflow optimization
Denial Prevention
Upfront claim scrubbing and validation to prevent denials before submission.
Pre-submission validation / Coding review / Eligibility verification / Authorization tracking
Recover Revenue Others Write Off
Our denial management experts overturn denied claims and prevent future denials. Find out how much revenue you're leaving on the table.
The Benefits for Your Practice
Expert denial management transforms rejected claims into recovered revenue
Recover Lost Revenue
Increase successful appeals compared to in-house efforts and recover previously denied claims with expert denial management.
Reduce Future Denials
Decrease overall denial rates through root cause analysis and process improvements. Identify and fix systemic issues that generate recurring denials.
Faster Resolution Time
Shorten appeal turnaround. Get your revenue faster with specialists who know payer processes and decision timelines.
Free Staff Resources
Free up staff time spent on appeals. Your team focuses on prevention and current claims instead of fighting old denials.
Expert Appeal Documentation
Professional appeals with proper clinical documentation, coding justification, and payer-specific requirements. Higher overturn rates through comprehensive submissions.
Continuous Process Improvement
Receive detailed denial trend reports and actionable recommendations. Transform denial data into preventive strategies that improve your entire revenue cycle.
Lost appeal rights due to missed deadlines represent permanent, unrecoverable revenue loss.
Getting Into Denial Management Claims
01Understanding Denial Reason Categories for Effective Appeals
Every payer attaches a standardized reason to each claim it denies, reduces, or adjusts, and that reason is the single most important clue for how to respond. Mastering these denial categories is fundamental to effective denial management because the specific reason dictates the appropriate appeal strategy, required supporting documentation, and likelihood of overturn success.
The categories you will actually meet
- Missing or incomplete information
- Duplicate claims
- Filed past the timely-filing deadline
- Medical necessity
- Non-covered service
- Missing prior authorization
Each of these requires a fundamentally different response: missing-information denials typically need the complete data resubmitted within a specific timeframe; medical-necessity denials require a formal appeal with clinical documentation supporting the service; and no-authorization denials may need retroactive authorization requests or peer-to-peer reviews.
Practices that categorize denials by reason can identify systemic patterns: a high volume of missing-information denials suggests front-end claim scrubbing failures, while recurring medical-necessity denials may indicate documentation deficiencies or diagnosis selections that do not support the service.
02The Appeal Is Usually Worth Making, and Almost Nobody Makes It
Two federal datasets, measured in completely different ways, land on the same conclusion.
KFF analyzed the federal Transparency in Coverage filings and found that marketplace insurers denied 19% of in-network claims in 2024, in a range from 3% to 36% depending on the insurer. Of roughly 85 million denied claims, consumers appealed fewer than 1%. Of the appeals that were filed, insurers upheld 66%, so about one in three appealed denials was reversed.
The federal audit of Medicare Advantage is starker. The HHS Office of Inspector General reviewed skilled nursing prior authorization denials across 19 plans in June 2024 and found that plans overturned 95% of appealed denials in favor of the enrollee, while only 18% of denials were appealed at all. A companion audit found long-term acute care denials overturned 36% of the time and inpatient rehabilitation denials 43%, with the inpatient rehab rate ranging from 14% to 86% depending on which plan issued the denial.
That spread is the tell. When one plan reverses 14% of its own denials on appeal and another reverses 86%, the denial is not tracking a consistent clinical standard. OIG attributed the highest denial rates to contractors deciding on the plans' behalf, later reversed by the plan itself once someone pushed back.
What this means for a practice
- A denial is a first position, not a final answer, and the reversal rates say so plainly.
- The economics favor appealing far more often than practices actually do.
- Nobody appeals claims that were never worked, which is why denial follow-up has to be somebody's standing job rather than what happens when there is time.
OIG put it in its own words: a 95% overturn rate "raises concerns about denials that were not appealed."
03Reconsideration vs. Formal Appeal: Choosing the Right Strategy
Reconsiderations and formal appeals are different tools. Picking the wrong one wastes time or misses the argument that would have won.
Reconsideration
A reconsideration asks the payer to look again at a claim denied for a correctable error, such as missing information, a coding mistake or a data entry slip. It usually needs no clinical argument: correct the claim or supply the missing item.
Formal appeal
A formal appeal challenges a coverage or medical necessity decision. It has filing deadlines, required documents and defined levels of review.
The five Medicare levels
- 01Redetermination by the Medicare contractor (request within 120 days).
- 02Reconsideration by a Qualified Independent Contractor (request within 180 days).
- 03Hearing before an Administrative Law Judge, when at least $200 is in dispute (request within 60 days).
- 04Medicare Appeals Council review (request within 60 days).
- 05Federal district court review, when at least $1,960 is in dispute in 2026 ($2,000 from January 1, 2027).
Commercial plans
Commercial appeals usually have internal levels followed by external review through an Independent Review Organization. Treat a medical necessity denial as a clinical argument, not a paperwork fix.
04Underpayment Identification and Recovery Strategies
Underpayments represent a substantial but often overlooked category of revenue leakage that differs from outright denials in that the claim is paid, but at a rate lower than the contracted amount. Underpayments are easy to miss precisely because the claim comes back marked paid, so nothing flags for follow-up and the shortfall compounds quietly.
Identifying underpayments requires systematic comparison of actual payments against contracted fee schedules for every claim, which most practice management systems can automate through payment variance reporting. ## Where underpayments come from
- Payer system errors applying the contracted rate
- Multiple-procedure payment-reduction rules applied incorrectly
- Separately payable services bundled together
- Visit or procedure levels downcoded without clinical justification
- Negotiated rate increases not applied on the contractual effective date
The distinction between underpayments and legitimate payment adjustments is critical.
Contractual adjustments, co-pay/deductible allocations, and coordination of benefits reductions are not underpayments, while payment amounts below the contracted fee schedule rate for a covered service are actionable.
Recovery typically means filing a payment dispute or reconsideration with the payer, providing the contract terms and demonstrating the shortfall. Your payer contract sets the window for disputing a payment, so timely identification is essential. Checking every payment against the contract as it posts catches shortfalls inside that window.
The Payer Side of Denial Management Reimbursement
Denial management strategies must be tailored to each payer's specific appeal processes, timelines, and decision-making criteria. From Medicare's five-level appeal structure to commercial payer peer-to-peer review opportunities, understanding payer-specific nuances is essential for maximizing denial overturn rates.
- Medicare redetermination requests must be filed within 120 days of the initial determination date. Submit the redetermination request in writing with a clear statement of disagreement and all supporting clinical documentation.
- Medicare claims denied for medical necessity should include the relevant local and national coverage policy citations in the appeal, demonstrating that the service meets established coverage criteria. Reference the specific coverage policy and covered indication.
- Duplicate-claim denials on Medicare are common when resubmitting corrected claims. Clearly flag the resubmission as a replacement or corrected claim to prevent it from being rejected as a duplicate.
- Medicare timely filing is 12 months from the date of service, but appeals of denied claims have separate deadlines at each appeal level. Track both the original filing deadline and each appeal-level deadline independently.
- MA plans frequently deny claims for lack of prior authorization on services that traditional Medicare covers without pre-approval.
- The MA plan reconsiders a denial once. If it upholds the denial, it must send the case to the Independent Review Entity itself.
- Expedited appeals for urgent services must be decided within 72 hours by MA plans. Request expedited review when a standard appeal timeline could jeopardize the patient's health or ability to regain maximum function.
- MA plans that deny coverage must provide a written Organization Determination explaining the denial reason, appeal rights, and filing deadlines. If this notice is missing or incomplete, you can also file a complaint with CMS.
- Each payer sets its own appeal window. Check the specific deadline on each Explanation of Benefits (EOB) and in your contract rather than relying on general guidelines.
- Peer-to-peer reviews are often available for medical necessity denials from commercial payers. Requesting a peer-to-peer conversation between the treating physician and the payer's medical director can overturn denials that written appeals cannot.
- State insurance department external review is available for commercial payer denials after internal appeals are exhausted. External review decisions are binding on the payer in most states.
- Commercial payers increasingly use automated clinical editing software that auto-denies based on how services are combined on a claim. Understanding which payer bundling rules trigger auto-denials enables front-end correction before claim submission.
- Implement a denial management dashboard that tracks denials by payer, denial reason category, service type, and provider. Monthly trending reveals systemic issues that can be addressed through process improvement rather than individual claim rework.
- Set automated alerts for appeal deadline tracking with escalation at 30-day, 15-day, and 5-day intervals before each filing deadline. Lost appeal rights due to missed deadlines represent permanent, unrecoverable revenue loss.
- Maintain a payer-specific appeal template library with pre-built clinical arguments for the most common denial reasons. Templates built around the payer's own criteria answer the denial better than generic form letters.
- Track denial overturn rates by appeal writer and strategy to identify which approaches are most effective for each payer and denial type. Use this data to continuously refine appeal strategies and allocate resources to the highest-value recovery opportunities.
Ready to Improve Your Denial Management Workflow
Let our experts show you how we can improve your operations and increase revenue.
Questions we get asked
- What is the difference between a rejection and a denial?
- A rejection never reached the payer's adjudication system, usually stopped at the clearinghouse for a formatting or data problem. A denial was adjudicated and refused. Rejections are cheaper and faster to fix, and are the ones most often lost because nothing appears on an aging report.
- Is it worth appealing small denials?
- Often yes, because the value is not only the single claim. A denial worked and logged tells you which upstream step produced it, and fixing that step is what stops the next fifty. Appeal economics alone would say ignore small claims; pattern economics say otherwise.
- How long do we have to appeal?
- Every payer sets its own window, and they differ widely. The practical risk is not one missed deadline but a backlog quietly ageing past several at once, which is why aged claims get worked oldest-first rather than by size.
- What causes most denials?
- Two categories come up again and again: eligibility and authorization problems created before the visit, and documentation that does not support what was billed. Both originate upstream of billing, which is why denial work that never reports causes back to intake keeps producing the same denials.
- Can you work denials we have already written off?
- Sometimes, depending on how old they are and each payer's filing limits. It is worth reviewing before writing anything off permanently, because written-off claims never appear in any report and so never get counted as a loss.