Every Denial is a Solvable Problem — We Solve Them All, and Then Prevent Them
The average practice loses 5-10% of revenue to unworked denials. These aren't charity — they're earned dollars payers are holding back on technicalities. Our denial management team fights for every cent, then engineers systems to prevent recurrence.
What We Do
The moment a denial is received, our team categorizes it using the CARC/RARC code system and maps it to primary denial categories — eligibility, authorization, coding, documentation, timely filing, duplicate, or contractual. Root cause analysis determines whether the denial originated at registration, documentation, coding, or billing.
For clinical denials, our team prepares detailed, evidence-based appeal letters citing CMS coverage policies, LCD/NCD documentation, clinical literature supporting medical necessity, and your provider's clinical rationale. We know the regulatory language that gets appeals reversed.
Every payer has different appeal timelines. For Medicare, we manage all five appeal levels: Redetermination (120 days), QIC Reconsideration (180 days), ALJ Hearing (60 days), Medicare Appeals Council, and Federal District Court. For commercial payers: Internal appeal, External IRO review, State Insurance Department complaint.
By tracking denial patterns across payers, providers, procedure types, and categories, we identify systemic vulnerabilities and implement process corrections upstream — at registration, documentation, coding, or billing — to prevent the same denial from occurring again.
We maintain a constantly updated knowledge base of payer-specific denial behaviors — which payers routinely deny specific CPT codes, which require specific documentation, and which appeal processes favor specific language.
What's Included
Root Cause Analysis
CARC/RARC categorization and upstream identification
Appeal Letter Writing
Evidence-based appeals with clinical citations
Timely Appeal Filing
Deadline tracking for every payer
Multi-Level Escalation
All 5 Medicare levels + commercial IRO
Denial Trend Analysis
Pattern identification and upstream prevention
Payer Intelligence
Payer-specific denial behavior knowledge base
Why This Matters for Your Revenue
Frequently Asked Questions
All types — eligibility, authorization, medical necessity, coding, documentation, timely filing, duplicate, bundling, and contractual denials.
Our evidence-based appeal process achieves a 73% overturn rate across all payer types and denial categories.
Yes. Government payer appeals follow specific regulatory frameworks (Medicare has 5 levels) that differ significantly from commercial appeal processes.
We track denial patterns and implement upstream corrections — fixing registration workflows, documentation templates, coding practices, or billing procedures that cause recurring denials.
Yes. We review aged denials to determine which are still within appeal timelines and pursue recovery on every viable claim.
We escalate to the next appeal level. For commercial payers, this can include external IRO review and state insurance department complaints. We exhaust all available options.