SolutionsDenial management
Denial management
Working denials to resolution — and removing the cause.
Why this one
costs you money.
A denial is two problems in one. There is the claim that has not been paid, and there is whatever caused it — which is still sitting in the process, still producing denials. Working the first without fixing the second means the same denial arrives again next month.
Exact Core works denials to resolution and categorises them by cause, so that the small number of causes producing most of the volume can be removed rather than reworked indefinitely.
What this discipline
actually involves.
- Denials categorised by root cause, not just by payer or dollar value.
- Appeals prepared where the denial is appealable and worth appealing.
- Rejections, denials and underpayments handled as three distinct problems.
- Recurring patterns fed back into coding and front-end processes.
- Appeal deadlines tracked so the right to appeal is never lost to the calendar.
The method.
Categorise
Every denial is coded to a root cause — eligibility, authorisation, coding, documentation, timeliness, contract — rather than filed by payer or by dollar value. Without categories there is no way to tell a front-end problem from a coding one.
Triage
Denials are sorted into appealable, correctable and final. Effort goes where there is something to recover; a genuinely final denial is closed rather than worked forever.
Appeal
Appeals are prepared against the specific denial reason, with the documentation that answers it, and tracked against the payer’s appeal deadline.
Feed back
Recurring causes are reported back into coding, eligibility and front-desk processes. This is the part that reduces next month’s volume.
What you receive
- Denials grouped by root cause, ranked by volume and value.
- Appeal status and deadline tracking.
- The recurring causes, and where in the cycle they originate.
- Rejections, denials and underpayments reported separately.
The failure modes.
Denials worked one at a time
Reworking a denial recovers one claim. Removing its cause recovers every future one.
No root-cause categorisation
Without categories you cannot tell a coding problem from an eligibility problem.
Appeals abandoned
Many denials are appealable and simply never get appealed.
What clients say.
What impressed us most was their approach to denials. They don’t simply work a denied claim and move on. They look for the reason behind the denial and help identify what needs to change to prevent the same issue from happening again.
The value for us isn’t just getting a denied claim resolved. It’s understanding why it happened and addressing the underlying issue. That has helped us take a much more proactive approach to denial management.
We had a significant amount of AR that needed more focused attention. Exact Core helped us prioritize the accounts based on recoverability and gave our team much better visibility into what was actually being worked.
About denial management.
What is the difference between a rejection and a denial?
A rejection never entered the payer’s adjudication system — it failed a format or eligibility check at the clearinghouse or front end, and can usually be corrected and resubmitted. A denial was adjudicated and refused. They have different causes, different fixes and different deadlines, and combining them into one number hides both.
Are all denials worth appealing?
No. Some are correct, and some cost more to appeal than they will ever return. Triage decides which are appealable and worth the effort; the rest are corrected, rebilled, or closed as a decision rather than by neglect.
How far back can denials be worked?
That depends on each payer’s timely-filing and appeal windows, which vary by contract. Establishing which outstanding denials still carry a live right of appeal is part of the initial assessment.
Will this reduce denials, or only recover them?
Recovery is the immediate work; reduction comes from the categorisation. Denials that trace to a cause outside billing — an eligibility check that was never done, a note that did not support the code — can only be reduced by changing that step.
The other five disciplines
Revenue leaks between them, which is why they are managed as one cycle.
Medical billingMedical codingAR ManagementCredentialingEligibility verificationPatient supportFront office management
How is denial management
performing for you?
A revenue assessment reviews all eight disciplines end to end and shows you where the reimbursement is going.