Service

Denial management and appeals

A denial is not a decision — it's the start of a process most practices never finish. We work every denial to resolution and fix the cause so it stops recurring.

Get a free A/R analysis Book a 15-minute call

The problem this fixes

Roughly one in ten claims is denied on first submission, and a large share of those are never appealed. Not because they're unwinnable — because appealing takes time the practice doesn't have, and filing deadlines pass quietly.

The second failure is worse: practices fix denials one at a time without ever asking why they keep happening. The same missing modifier, the same eligibility gap, the same auth requirement, month after month.

There is also a measurement problem underneath it. Most practices can state a denial rate but not a denial distribution, and the distribution is where the action is. Eligibility denials are a front-desk fix, authorisation denials are a scheduling fix, and bundling denials are a coding fix. Reported as a single percentage, all three look like the same problem and none of them gets solved.

What goes wrong when this is done badly

Four failure modes we see repeatedly, and each one is a process problem rather than an effort problem.

Filing denials instead of working them

A denial in a folder is a claim with a countdown on it. Appeal windows close quietly, and by the time anyone looks, the question is no longer whether the appeal would have won.

Appealing without reading the policy

A medical necessity appeal that argues the medicine rather than the payer's published criteria will fail even when the care was obviously appropriate. The reviewer applies the policy.

Reflexive modifier 59

Appending a distinct-service modifier to every bundling denial converts a coding question into an appeals workflow, and produces a usage profile that invites a records request.

Fixing claims and never fixing causes

The same missing modifier, the same eligibility gap, the same auth requirement, month after month. Working denials one at a time keeps the lights on; working them by category is what makes the volume fall.

What's included

Every item below is a deliverable, not a capability statement.

Denial triage and categorisation

Every denial coded by CARC/RARC, not filed in a folder.

Root-cause analysis

Across denial volume, not claim by claim.

Corrected claim submission

Rejections fixed and resubmitted inside the window.

First-level and second-level appeals

With the supporting documentation the payer actually requires.

Clinical appeals

Including medical necessity narratives.

Peer-to-peer review coordination

Scheduled with the ordering provider.

Payer policy research

LCD, NCD, and medical policy bulletins.

Timely filing deadline tracking

By payer, so nothing expires unworked.

Underpayment identification

Against your contracted rates.

Prevention feedback

Into coding and front-desk process, every month.

How it works

1 Triage Every denial is categorised by CARC/RARC code and scored on appeal window and value.
2 Root cause We look at the pattern across volume, not one claim at a time.
3 Correct or appeal Corrected claims go back immediately; appealable denials get a written appeal with documentation.
4 Escalate Second-level appeals, clinical narratives, and peer-to-peer review where the case needs it.
5 Prevent Monthly root-cause reporting feeds back into coding and front-desk workflow.

Common denial categories we work

Category	Typical CARC	Root cause
Eligibility / coverage	CO-27, CO-31	Coverage not verified before the visit
Prior authorisation	CO-197	Auth not obtained or not attached
Medical necessity	CO-50	Diagnosis doesn't support the procedure under payer policy
Bundling / NCCI	CO-97, CO-236	Services billed separately that payer bundles
Missing or invalid modifier	CO-4, CO-16	Modifier omitted or wrongly applied
Duplicate claim	CO-18	Resubmission without correction
Timely filing	CO-29	Claim filed past the payer deadline
Coordination of benefits	CO-22	Primary payer not billed first
Non-covered service	CO-96	Service excluded under the plan
Credentialing / enrollment	CO-B7	Provider not enrolled or effective date wrong

CARC codes are maintained by the X12 Claim Adjustment Reason Code committee. Payer usage varies; we work to each payer’s own remittance conventions.

What you get back

A monthly denial report by CARC code, payer and provider
Appeal outcomes tracked with dates and reference numbers
A prevention action list, prioritised by recurring volume
Filing and appeal deadlines monitored by payer

Who this is for

Practices with a denial rate above 8%
Practices where denials are filed rather than worked
Practices that want denials worked without changing billers
Practices seeing the same denial reason month after month

What we measure

The numbers this service actually moves. You see all of them weekly, in your own system, with the benchmark alongside.

Denial rate by CARC category Not one number but a distribution. Eligibility denials, authorisation denials and bundling denials have completely different fixes, and the aggregate rate tells you none of that.
Appeal win rate Appeals overturned as a share of appeals filed, by payer and by denial reason. A low rate against one payer is a policy problem; a low rate across all of them is a documentation problem.
Denial turnaround time Days between a denial landing on the remittance and someone acting on it. This is the number that decides whether a filing window is still open when the work starts.
Recurrence rate The share of denials this month that repeat a root cause we reported last month. It is the honest measure of whether prevention is working, and it is the one most billing companies do not publish.

Benchmark ranges are sourced from MGMA and HFMA MAP Keys. MedBil's own figures are published only with a stated measurement window, per specification section 12.7.

Where this matters most

The specialties where this part of the cycle carries the most risk and the most recoverable revenue.

Gastroenterology Screening vs. diagnostic colonoscopy, modifier 33/PT, auth Dermatology Lesion coding by size and site, cosmetic vs. medical, pathology Physical Therapy Timed vs. untimed units, the 8-minute rule, therapy caps, plan of care Urgent Care High volume, S-codes, place of service, self-pay mix OB/GYN Global obstetric package, antepartum/postpartum splits, ultrasound Wound Care Debridement by depth, skin substitutes, HBOT, documentation of measurements

Proof

Start with your own numbers

We measure your denial rate, A/R ageing and net collection rate against industry benchmarks before you commit to anything. You keep the analysis either way.

90 days of claims data, no patient identifiers needed
A written analysis, not a sales deck
No contract, and no obligation to proceed
Client results published with a stated measurement window, once available

Questions about denial management & appeals

Can you work denials that are already old?

Yes, as long as the filing or appeal window is still open. We check first.

Do you write clinical appeals?

Yes, including medical necessity narratives and peer-to-peer coordination.

Can you take denials only, without full billing?

Yes — this is a common entry point.

How do you stop denials recurring?

Root-cause reporting feeds back into coding and front-desk workflow every month.