Solution: High Denial Rate
Here's Exactly Why, and How We Fix It.
A denial rate above 10% is not bad luck. It's a process failure, and it has a specific root cause in your eligibility verification, coding, or authorization workflow. We find it, fix it upstream, and get your clean claim rate above 98%.
Root Causes
Every denial has a CARC/RARC code that identifies the reason. We categorize yours, find the upstream pattern, and eliminate it.
Patient coverage lapsed, wrong payer ID, or plan not active on date of service. Accounts for 23% of all denials and is 100% preventable with pre-visit verification.
Procedure performed without active authorization, or authorized CPT code doesn't match billed code. Especially damaging in high-auth specialties like cardiology and pain management.
Missing modifier 25, incorrect modifier 59 usage, unbundling violations, or wrong place-of-service code. Payers use automated claim editing to catch these instantly.
Diagnosis code doesn't support the medical necessity of the billed procedure per payer LCD/NCD policy. Usually correctable with additional documentation, if caught before write-off.
Claims submitted after the payer's timely filing deadline (typically 90–180 days from date of service). These denials are usually unrecoverable; prevention is the only fix.
Provider not enrolled with payer, NPI mismatch, or taxonomy code error. Creates a cascade of denials across every claim from that provider until resolved.
Our Approach
We pull every denial from the last 90 days and categorize by CARC/RARC code, payer, CPT code, and root cause. This creates a priority-ranked list of the top 3–5 denial drivers for your specific practice.
Most billing companies work denials after they happen. We fix the process that caused them. If 35% of your denials are auth-related, we rebuild your auth workflow, so those claims never deny in the first place.
We maintain a current library of payer-specific edit rules, LCD policies, and modifier requirements for all major commercial and government payers. Claims are scrubbed against actual payer rules before submission.
You receive weekly denial reports broken down by payer, root cause, and CPT code. Trending is the only way to confirm the fix is working, and to catch new denial patterns as payers update their rules.
At 90 days, we present a before/after comparison: denial rate, clean claim rate, Days in A/R, and net collection rate. If we haven't shown measurable improvement, we extend service at no charge.
Illustrative Scenarios
We'll categorize every denial from the last 90 days, identify root causes, and show you the dollar value of the revenue you're losing, at no charge.