Denials & Appeals
If the same denial comes back next month, nobody fixed it.
Most practices rework denials. Far fewer classify them. MBS groups every denial by reason code, payer, and provider, appeals what is winnable on the clinical record, and pushes the confirmed cause back upstream into eligibility, coding, and claim scrubbing so the denial stops repeating.
94%
Appeals overturned
of denials we appeal
98.2%
First-pass clean claim rate
trailing 12 months, all clients
Root cause
Every denial grouped before it is reworked
reason code, payer, provider, and CPT
HOW WE WORK DENIALS
Three rules that decide whether a denial program works
A denial is data before it is a task
Reworking denials one by one keeps the cash moving and changes nothing. Every denial we touch is first classified — reason code, payer, provider, location, CPT, and whether it was avoidable at submission. That classification is what turns a queue into a fix list.
Appeal what is winnable, and say so when it is not
Some denials are worth a full clinical appeal. Some need a corrected claim. Some are correctly denied and should be written off today rather than aged for six months. We separate those three buckets openly instead of billing you for motion.
The fix belongs upstream
If the same reason code returns next month, the appeal was a bandage. Findings go back into eligibility checks, coding rules, and claim scrubbing so the denial stops being generated in the first place.
The denial ledger: reason, cause, control
These are the reason codes that carry most denied dollars in outpatient billing, what actually causes them, and the control we put in place so the same code stops returning.
No authorization / auth mismatch
Auth obtained for the wrong CPT, units, place of service, or date span.
Pre-service auth verification against the scheduled code set; retro-auth requested where the payer allows it.
Eligibility / coverage terminated
Coverage checked at intake but not on the date of service.
Eligibility re-verified before submission, with secondary and COB order confirmed.
Medical necessity
Documentation does not tie the service to the payer's own published criteria.
Appeal built on the clinical record citing payer policy; recurring patterns returned to the clinical lead.
Coding — modifier, bundling, level
Missing modifier, NCCI edit, or an E/M level the note does not support.
Coder review before resubmission and a scrubber rule added for the same pattern.
Timely filing
Claim sat in a worklist nobody owned until the window closed.
Aging worked by filing deadline first, with proof-of-timely-filing packets assembled where a payer disputes receipt.
Duplicate / already adjudicated
Resubmission without a corrected-claim indicator or original claim reference.
Corrected-claim workflow with the original claim number carried through.
Credentialing / provider not on file
Billing began before enrollment or contract load completed.
Effective dates confirmed in writing before charges release — see credentialing below.
THE CADENCE
What happens, and when
Week one — inventory and baseline
We pull the full denial and rejection history we can access, group it, and give you a baseline denial rate by payer and reason. No recommendations before that number exists.
Ongoing — appeals filed on the record
Appeals are drafted with the supporting documentation attached, tracked to a decision, and escalated to provider reps when a payer misses its own response window.
Ongoing — prevention at submission
Confirmed root causes become scrubber edits, eligibility checkpoints, and coding notes, so the same denial does not need a second appeal.
Monthly — what changed and why
One report: denial rate by reason and payer, overturn outcomes, dollars recovered, write-offs taken deliberately, and the prevention rules added that month.
Works with your billing team
Denial management is available as a standalone scope. Your team keeps submitting; we take the denial and appeal queue and hand back the prevention findings.
Payer-specific playbooks
Appeal formats, deadlines, and escalation ladders differ per payer. We keep them per plan rather than sending one generic letter everywhere.
Write-offs stay a decision
Nothing is written off silently. Uncollectible balances are presented with the reason so the adjustment is yours to approve.
Audit-ready trail
Every appeal keeps its submission date, reference number, payer contact, and outcome, so the file stands up in a payer dispute.
Denial questions we get on every call
What denial rate should we expect?
Industry sources generally put a healthy first-pass denial rate in the single digits, and the honest answer is that yours depends heavily on payer mix and specialty. Rather than quote you a target, we baseline your current rate by payer and reason in the first weeks and then report movement against your own starting point.
Do you work old denials or only new ones?
Both, but they are separate scopes. New denials are a continuing workflow; a backlog of aged denials is a fixed-scope cleanup project prioritized by filing deadline and recoverability. Mixing the two is how backlogs never get finished.
Who writes the appeal letters?
Our appeals staff, using the clinical documentation and the payer's own medical policy. Where a physician statement or peer-to-peer is required, we prepare the packet and schedule it so your provider spends minutes on it, not hours.
Will you tell us when a denial is our fault?
Yes, and that is most of the value. Front-desk eligibility gaps, documentation that does not support the level billed, and missed auth steps are common causes, and they cannot be fixed by appeal.
Can you work in our system?
Yes. We work inside your existing EHR/PM and clearinghouse rather than asking you to move, so denial history, notes, and appeal documentation stay in your record.
How is this priced?
As a percentage of collections — that is the only model we use. It is how continuing denial management is billed, and a backlog cleanup is quoted the same way against what we recover. Your rate depends on volume and the age of the inventory, and we quote it after seeing the inventory.
Where denial work connects
A/R Recovery
Aged claims and denials past the easy window, worked by recoverability and filing deadline.
Medical Coding
Modifier, bundling, and E/M accuracy — the upstream fix for a large share of denials.
Credentialing & Enrollment
Provider-not-on-file denials start here, before a single claim is submitted.
Send us 90 days of denials
We will group them by reason and payer and tell you which are winnable, which are preventable at submission, and which should be written off today — before you commit to anything.
How does your A/R and denial rate compare?
Free benchmark tool — enter six numbers, see your bands against published industry sources, and download a branded PDF.