Denial Management That Gets to 2.1% — And Stays There
The industry average denial rate is 8–12%. Most practices accept this as normal. We don't. Our denial management service doesn't just fix denied claims — it eliminates the patterns that cause them.
Missing or Incorrect Authorization
Payer required prior authorization wasn't obtained, or the auth on file doesn't match the procedure billed. We track auth requirements by payer and procedure proactively.
Incorrect CPT, ICD-10, or Modifier
Unbundling violations, wrong modifier, missing specificity in diagnosis codes, or CPT/ICD-10 combination not supported. Our coders review every claim before submission.
Patient Not Eligible on DOS
Insurance lapsed, wrong plan billed, or patient has secondary coverage not billed. We verify eligibility 48 hours before the appointment and again at claim submission.
Claim Submitted Outside Filing Window
Every payer has a timely filing deadline — from 90 days to 1 year. We track filing windows by payer and submit within 5 business days of service for all new claims.
Service Not Medically Necessary
Payer's clinical criteria not met or not documented. We identify medical necessity requirements per payer and flag documentation gaps before the claim goes out — not after the denial arrives.
COB / Primary vs Secondary Billing
Primary payer not billed first, or secondary claim submitted without primary EOB. We manage COB sequencing for all multi-payer patients automatically.
Stop Denials Before Submission
We scrub every claim against payer-specific edits before it leaves the system. Our 98.4% first-pass clean claim rate reflects what happens when you catch errors at the source.
Chase Every Denial With a Full Appeal
When a claim is denied, we don't accept it. Every denied claim gets reviewed, categorised, and appealed with payer-specific documentation — within 48 hours of the denial ERA.
Eliminate the Pattern, Not Just the Claim
A single denied claim is a mistake. The same denial five times is a pattern. We track denial trends by payer, CPT, and provider — and update our processes to close the loop permanently.
Top Denial Categories Managed by RCMAXIS
Per our provider network, 2025–2026Baseline Assessment & Quick Wins
We audit your current denial queue and identify the top 3 denial reasons by volume. Easy wins — eligibility errors, missing modifiers — are corrected immediately. Existing denied claims begin the appeal process.
Process Corrections Take Effect
Pre-submission edits are configured for your payer mix. Auth tracking matrix is live. First-pass acceptance rate on new claims begins climbing. You receive your Week 4 baseline KPI report.
Denial Rate Drops Materially
As corrected processes compound, denial rate falls toward the 4–5% range for most practices. Appeal revenue begins posting — recovered claims from the first 30 days hit your bank account.
Steady-State 2.1% Target Reached
With systematic prevention in place, denial rate stabilises at or below 2.1% for most specialties. Monthly trend reports confirm root causes have been closed. 90-day performance review delivered.
Find Out Your Current Denial Rate — For Free
Our free $1,500 revenue audit includes a full denial pattern review: your top denial reasons by payer, CPT code, and provider — with a root cause attribution report and projected recovery.