Denial Management Services in USA

The Denial Management Crisis in 2026:
What Healthcare Providers Must Know

Rising Denial Rates and Payer AI

The denial landscape has shifted fast. Initial denial rates now average 12%, up from 10% just two years ago. That's a 20% jump.

Here's what's driving it: payers are deploying AI systems that reject claims faster than any human could review them. These algorithms flag high-dollar procedures and challenge medical necessity within seconds of submission. Your claim hits their system, and software decides its fate before a person ever looks at it.

Even after appeals, the final write-off rate hovers near 2.8%. Providers without strong healthcare denial management strategies are fighting a system designed to say no.

0 % Initial Denial Rate Up from 10% (2yr avg)

0 % Final Write-Off Rate Billions in lost industry revenue

New CMS Prior Authorization Rules (Effective January 2026)

The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) is now in effect. Impacted payers must respond to urgent requests within 72 hours and standard requests within 7 calendar days.

Sounds like progress? In practice, payers use automated algorithms that instantly deny claims missing even minor documentation. Faster decisions don't help when the answer is still no.

The WISeR Model Impact: Launched in NJ, OH, OK, TX, AZ, and WA, this requires new authorization workflows most providers haven't built yet, creating fresh denial exposure.

MedSole RCM stays ahead of these changes.

Our denial management team monitors payer policy updates daily, ensuring your claims meet current requirements before submission and your appeals leverage the latest regulatory standards.

Concerned about new requirements?

Schedule a free denial risk assessment

No obligation. Confidential analysis.

Types of Healthcare Claim Denials We Resolve

Not all denials work the same way. Some get fixed in hours. Others need clinical expertise and multi-level appeals. Understanding the denial type determines your resolution path.

Hard Denials

Hard denials are permanent rejections that can't be corrected or resubmitted. They happen when services aren't covered under the patient's plan or when you've billed for excluded procedures. MedSole identifies hard denial patterns to prevent future occurrences and advises on appropriate patient billing procedures.

Soft Denials

Soft denials are temporary rejections caused by correctable errors: wrong patient information, missing documentation, or coding inconsistencies. Our denial management specialists resolve soft denials within 24 to 48 hours by correcting errors, attaching required documentation, and resubmitting clean claims for immediate processing.

Clinical Denials

Clinical denials question medical necessity, level of care, or treatment appropriateness. These require clinical documentation improvement expertise to overturn. MedSole works with certified CDI specialists who build compelling appeals using evidence-based justifications that payers can't easily dismiss.

Technical Denials

Technical denials result from administrative errors: invalid CPT codes, incorrect modifiers, missing prior authorization, or timely filing violations. Our automated claim scrubbing catches these issues before submission. For existing denials, our appeals team corrects and resubmits with proper documentation.

Coding Denials

Coding denials stem from ICD-10, CPT, or HCPCS code errors: mismatches, bundling issues, or unsupported diagnosis codes. MedSole employs AAPC and AHIMA certified coders who review denied claims, identify the deficiency, and ensure corrected claims meet payer-specific requirements.

Authorization Denials

Authorization denials occur when required prior authorization wasn't obtained or has expired before service. Our proactive authorization tracking prevents these denials before you deliver care. For claims already denied, our appeals team handles retroactive authorization requests to recover the revenue.

Stop Losing Revenue to Claim Denials

Let MedSole's expert team handle your denial management and recover the revenue you deserve. Our specialists are ready to analyze your claims and develop a winning recovery strategy.

Get Free Consultation Call Us Now

Top Causes of Medical Billing Denials

Most claim denials trace back to the same handful of problems. Once you know what triggers them, prevention becomes straightforward.

8 Critical Codes

Select Denial Code

CO-16 Missing or Incorrect Patient Information CO-197 Lack of Prior Authorization CO-18 Duplicate Claims CO-181 Invalid Procedure Codes PR-96 Non-Covered Services CO-29 Timely Filing Exceeded CO-50 Medical Necessity Not Established CO-4 Incorrect Modifier Usage

CO-16

Missing or Incorrect Patient Information

Patient demographics don't match what the payer has on file. A single typo in name or date of birth triggers an automatic rejection.

The Challenge

Administrative errors in the intake process often lead to these denials. When patient data entered into the system deviates even slightly from the insurance record, be it a middle initial or a hyphenated name, the claim is flagged instantly.

Our Fix

We verify eligibility in real-time before every claim goes out. Our intelligent scrubbing technology cross-references patient data with payer databases to ensure a 100% match before submission.

Success Rate

98%

Pro Tip for Intake Teams

Scanning insurance cards instead of manual entry can reduce CO-16 denials by up to 45%. Ensure all staff are trained on OCR technology workflows.

CO-197

Lack of Prior Authorization

Required authorization wasn't obtained before the service date, or it expired before the patient came in.

The Challenge

Prior authorizations have strict validity windows that are easy to miss. Staff often schedule procedures without confirming the auth is still active, leading to automatic denials for services already rendered.

Our Fix

Our tracking system alerts your team before authorizations expire. We maintain a centralized auth calendar that sends automated reminders 7, 3, and 1 day before expiration.

Auth Compliance

99.2%

Authorization Best Practice

Always request authorizations for longer periods than needed. If a procedure might extend 2 weeks, request 30 days. The buffer prevents last-minute scrambles.

CO-18

Duplicate Claims

Same claim submitted multiple times, often by accident when staff aren't sure if the first one went through.

The Challenge

When billing systems lag or confirmation screens don't load, staff often click submit again. Each duplicate creates a denial, and cleaning up the mess wastes hours that could go toward productive work.

Our Fix

Automated duplicate detection stops double submissions before they happen. Our system flags identical claims within a 30-day window and requires manual override to proceed.

Duplicates Blocked

100%

Workflow Improvement

Implement a claim status dashboard visible to all billing staff. Real-time visibility into submission status eliminates the uncertainty that causes duplicate submissions.

CO-181

Invalid Procedure Codes

CPT codes don't match documentation or the code set is outdated. Payers reject instantly.

The Challenge

CPT codes update annually, and deleted codes remain in many billing systems long after retirement. Staff using outdated code sets or mismatched diagnosis-procedure combinations trigger immediate rejections.

Our Fix

Certified coders validate every code before submission. Our system updates automatically with new code releases and flags deprecated codes the moment they're selected.

Code Accuracy

99.7%

Annual Code Update Protocol

Schedule a mandatory code review every January. Cross-reference your most-used codes against the new CPT release to catch deletions before they cause denials.

PR-96

Non-Covered Services

Service isn't covered under the patient's plan. You find out after you've already delivered care.

The Challenge

Patients often don't know what their plan covers, and neither does your front desk. Delivering care before confirming coverage creates write-offs that can't be recovered from the payer.

Our Fix

Pre-service eligibility checks identify coverage gaps before you deliver care. We verify specific procedure coverage, not just active enrollment, so you know exactly what will pay.

Coverage Verified

97%

Coverage Verification Script

Train front desk to ask payers: "Is CPT [code] covered for diagnosis [ICD]?" Getting procedure-specific confirmation prevents PR-96 surprises.

CO-29

Timely Filing Exceeded

Claim submitted after the payer's deadline. Once that window closes, the revenue is gone forever.

The Challenge

Different payers have different filing limits, ranging from 90 days to one year. Claims stuck in holds, pending corrections, or simply overlooked often miss their windows permanently.

Our Fix

Our workflow maintains a 99% timely filing rate across all payers. Automated aging alerts escalate claims approaching deadlines, ensuring nothing slips through the cracks.

Timely Filing

99%

Filing Deadline Tracker

Create a payer-specific deadline chart and post it where billers can see it. Color-code by urgency: 90-day payers in red, 180-day in yellow, 365-day in green.

CO-50

Medical Necessity Not Established

Documentation doesn't support why the service was clinically needed. Payers deny without clear justification.

The Challenge

Physicians document for clinical purposes, not billing purposes. When notes lack specific language supporting medical necessity, payers have grounds to deny even appropriate services.

Our Fix

CDI specialists review charts to ensure documentation meets payer standards. We identify gaps before submission and work with providers to strengthen supporting language.

Appeal Success

87%

Documentation Enhancement

Encourage providers to answer "why" in every note. "Patient requires X because of Y" creates the medical necessity link that "Patient received X" does not.

CO-4

Incorrect Modifier Usage

Modifiers don't align with procedure codes. A common error that triggers automatic denials.

The Challenge

Modifier rules vary by payer, procedure, and even provider type. Using modifier 25 when 59 is required, or omitting a required modifier entirely, results in immediate claim rejection.

Our Fix

Coding audits catch modifier errors before claims leave your system. Our rules engine applies payer-specific modifier logic automatically, eliminating manual guesswork.

Modifier Accuracy

99.5%

Modifier Quick Reference

Build a cheat sheet of your top 20 procedures with their required modifiers by payer. Post it at every coding station for quick reference during claim entry.

Stop Losing Revenue to Preventable Denials

Our denial management specialists can help you identify patterns, fix root causes, and recover more revenue from every claim.

Schedule Your Free Denial Analysis

The MedSole RAPID™ Denial Management Process

Most billing teams handle denials reactively. Claims get rejected, sit in a queue, and someone eventually gets around to them. By then, timely filing deadlines are looming.

Our denial management specialists take a different approach. The RAPID™ denial management process is built for speed, prevention, and measurable outcomes.

Within 24 Hours

Review & Root Cause Analysis

Every denied claim enters our denial management workflow immediately. Within 24 hours, our denial management specialists categorize it by type: clinical, technical, coding, or authorization. They pull the CARC and RARC codes and dig into what went wrong.

Was it a registration error? Coding mistake? Documentation gap? Payer policy issue? Root cause analysis tells us exactly where the breakdown happened. That insight drives the immediate fix and long-term prevention.

Within 48 Hours

Action & Appeal Submission

Once we know the cause, we move fast. Soft denials get corrected and resubmitted within 48 hours. Hard denials go through our appeals management workflow.

For appeals, we build payer-specific packages with supporting clinical documentation, LCD/NCD references, and evidence that's hard to argue against. Complex medical necessity cases? Our clinical documentation specialists coordinate peer-to-peer reviews with payer medical directors.

Ongoing Monitoring

Prevent Future Denials

Fixing a denial is only half the job. The other half is making sure it doesn't happen again.

Insights from our root cause analysis feed back to your front-end team, coders, and documentation staff. We update workflows, configure claim edits, and provide targeted training when patterns emerge.

The goal isn't just to recover revenue this month. It's to eliminate recurring denials permanently.

Monthly Reporting

Insight & Analytics

You can't fix what you can't see. That's why we provide comprehensive denial analytics every month.

You'll know your denial rate by payer, denial dollars by category, appeal success rates, and trending patterns. Monthly reports highlight improvements and emerging problems. We benchmark your performance against industry standards.

This data drives real decisions about payer contracts, coding practices, and operations.

Measurable Outcomes

Deliver Results

Here's what the RAPID™ denial management process delivers: denial rates below 4%, appeal success rates above 85%, AR days reduced by 40%, and revenue recovery improvements of 20% to 35%.

Every action gets tracked. Every result gets measured. And the process keeps improving based on what the data tells us.

Our commitment doesn't end with numbers. We provide ongoing support, regular strategy sessions, and continuous optimization to ensure your revenue cycle stays healthy and efficient for the long term.

Ready to implement a proven denial management process?

Schedule your free consultation

What We Cover

Our Complete Denial Management Services

Fixing denials isn't one task. It's six different skill sets working together, from initial identification to long-term prevention. Here's what our claim denial management services cover and what you should expect from each.

Denial Identification & Tracking

We monitor every claim from submission to payment, catching denials within hours of payer adjudication. Our tracking system sorts each one by reason code, dollar value, and aging so high-priority claims get immediate attention. Real-time dashboards show you exactly which denials need action, which are in progress, and which have been resolved—without waiting for a monthly report.

Appeal Preparation & Submission

Our appeals management team builds payer-specific appeal packages tailored to each denial reason. Every package includes relevant clinical documentation, medical policy references, and evidence-based arguments. We manage multi-level appeals—first through third—all the way to final resolution, including external reviews and ALJ hearings when the situation requires it.

Coding Denial Management Services

Coding denials need specialized expertise most practices don't have on staff. Our AAPC and AHIMA certified coders review denied claims for ICD-10, CPT, and HCPCS accuracy. We correct errors, apply the right modifiers, and confirm documentation supports every code submitted. Resolution happens within 48 hours of identification.

Clinical Documentation Improvement (CDI)

Medical necessity denials won't get overturned with a generic appeal letter. Our CDI specialists work directly with your clinical team to strengthen documentation before submission and build compelling justifications when appeals are needed. If a payer pushes back, we coordinate peer-to-peer reviews with their medical directors to resolve the dispute.

AR Denial Management in Medical Billing

Unresolved denials sit in aging buckets, quietly draining your cash flow. Our AR denial management integrates denial resolution with comprehensive accounts receivable follow-up so nothing slips through the cracks. High-dollar denials nearing timely filing deadlines get prioritized first, because once that window closes, the revenue is gone for good.

Denial Prevention & Analytics

Resolving denials is necessary. Preventing them is where the real money is. We analyze denial patterns, implement claim edits, update workflows, and train your staff to stop repeat issues at the source. Predictive analytics flag at-risk claims before submission, catching problems while they're still fixable. Monthly reports track what's working, where gaps remain, and how your denial rate compares to industry benchmarks.

Complete Denial
Management

Six specialized skill sets working together as one unified system—from the moment a denial hits to permanent prevention. Every claim tracked, every dollar pursued, every pattern eliminated.

Stop leaving revenue on the table. Let our six-step denial management system recover what's yours and prevent future losses.

Get Your Free Denial Audit Free consultation · No commitment required · Results within 30 days

Who We Serve

Healthcare Providers We Serve Across the USA

Denial patterns aren't the same across every practice type. A solo family medicine office doesn't deal with the same payer pushback as a 200-bed hospital. That's why our healthcare denial management services are built around the specific challenges each provider type actually faces.

Physician Practices & Medical Groups

Small practices and multi-specialty groups share one problem: limited staff wearing too many hats. Your billing person is also handling patient calls, posting payments, and chasing authorizations. Denials pile up because there's simply no bandwidth to work them properly. We step in as your dedicated denial team, keeping resolution moving without pulling your staff away from everything else they're juggling.

Hospitals & Health Systems

Hospital denial management is a different animal. You're dealing with DRG downgrades, inpatient versus observation disputes, and medical necessity challenges on high-dollar cases. Our hospital denial management process includes physician advisor coordination, peer-to-peer review support, and stratification by dollar value so the biggest recovery opportunities get worked first.

Specialty Clinics & ASCs

High-volume procedures and specialty-specific payer rules create denial exposure that general billing teams often miss. We stay current on CMS requirements, including the ASC prior authorization demonstration, and handle the payer-specific nuances that keep your surgical cases paid correctly and on time.

Behavioral Health & Ancillary Providers

Behavioral health sees some of the highest denial rates in the industry. Level-of-care disputes, authorization complexities, and documentation standards that vary wildly between payers make this space uniquely frustrating. Our denial management solutions are tailored to mental health, substance abuse, and ancillary service requirements so your clinical team can focus on patients, not paperwork.

We serve healthcare providers in all 50 states. If denials are costing your organization revenue, we can help you find out exactly where and how much.

Find Out What You're Losing Free denial analysis · All 50 states · No obligation

Why MedSole RCM

Why Healthcare Providers Choose Us for Denial Management

When you outsource denial management services, you're trusting someone else with your revenue. That's not a small decision. Here's what makes working with us different from other denial management companies, and why it matters to your bottom line.

Proven Results

Our clients see denial rates drop below 4% vs. the 12% industry average. Appeal success above 85%, revenue recovery improves 20–35%.

48-Hour Turnaround

We begin working every denied claim within 48 hours. Payers have strict appeal windows — every day a denial ages is closer to lost revenue.

Certified Expertise

AAPC & AHIMA certified coders, CDI specialists, and RCM professionals with 10+ years experience — without the cost of hiring in-house.

Technology + Human Judgment

AI flags at-risk claims before submission. Complex appeals get human experts who understand clinical context and peer-to-peer reviews.

Complete Transparency

Real-time dashboards, monthly performance reports by payer & category, and a dedicated team just a phone call away.

HIPAA Compliance & Security

Strict HIPAA protocols, enterprise-grade security, and regular third-party audits protect your data at every step.

See the difference a dedicated denial management partner makes. Start with a free assessment of your current denial landscape.

Schedule Your Free Assessment No commitment · Results within 30 days · All 50 states

Technology & Automation

Advanced Denial Management Technology & Automation

Payers are using algorithms to deny claims faster than your staff can work them. That's the reality. If your denial management process still runs on spreadsheets and manual tracking, you're bringing a clipboard to a software fight. Our denial management automation tools level the playing field.

Predict

Denial Prediction Engine

Most denials are predictable if you know what to look for. Our prediction engine scores every claim before it goes out the door, flagging the ones most likely to get rejected. Missing modifiers, documentation gaps, coding mismatches: the system catches these while there's still time to fix them. Practices using this technology typically see initial denial rates drop by up to 25%. Catching a problem before submission costs you seconds. Fixing it after a denial costs you weeks.

Automated Appeals Workflow

Building appeals by hand is slow, and mistakes happen when your team is copying claim details between systems. Our automated workflow pulls claim data, diagnosis codes, and supporting documentation into payer-specific appeal templates. Validation checks run before anything gets sent, confirming the appeal meets submission requirements. Your staff spends less time on paperwork and more time on cases that need clinical judgment.

Automate

Analyze

Real-Time Analytics Dashboard

You can't fix what you can't see. Our denial management analytics dashboard gives you live visibility into denial rates, appeal status, recovery amounts, and trending patterns. Need to know which payer is responsible for 40% of your denials? Two clicks. Want to see how your coding denial rate compares to last quarter? It's right there. That kind of clarity drives smarter decisions about payer negotiations, staffing, and workflow changes.

See how our technology catches denials before they happen and recovers the ones that slip through.

Request a Technology Demo Live demo · No commitment · See your data in action

Verified Outcomes

The Results Our Denial Management Clients Achieve

Numbers tell the real story. Not promises, not projections. Actual results from practices and hospitals that were dealing with the same denial problems you're facing right now. Here's what changes when denial management is handled properly.

Performance Metrics

We track six core metrics for every client. Here's how our averages compare to industry benchmarks.

Initial Denial Rate

Industry Avg 12%

Our Clients <4%

↓ 67% reduction

Clean Claim Rate

Industry Avg 85%

Our Clients 98%+

↑ 15% improvement

Appeal Success Rate

Industry Avg 50%

Our Clients 85%+

↑ 70% improvement

AR Days

Industry Avg 55+ days

Our Clients <35 days

↓ 36% reduction

Net Collection Rate

Industry Avg 91%

Our Clients 96%+

↑ 5% improvement

Denial Write-Offs

Industry Avg 2.8%

Our Clients <1%

↓ 64% reduction

💰

That 5% jump in net collections might look small on paper. For a practice collecting $2 million annually, it's $100,000 that was walking out the door every year.

Client Success Stories

Real feedback from real healthcare providers

"I cannot thank Medsole RCM for all they… I was previously using a different billing company who was making several mistakes with my billing, I was not getting paid and it was a complete mess. I switched over to Medsole RCM at the end of August the week of my wedding and I am so happy I did. Medsole has been amazing. Andrew has been helping me with all of my billing and he even was able to get me a higher reimbursement rate with two insurance companies. I cannot wait to continue to grow my private practice with Medsole!."

Isabella Saffioti

Occupational Therapist
Little star Pediatric Therapy

"Remarkable communication and efficiency… The communication and efficiency working with Scott at Medsole has been remarkable. All of my questions are answered promptly and with thoroughness and conciseness. In today's society of inefficiency and poor follow through and unremarkable customer service I have been extremely pleased with my experience in working with Medsole."

Brooke Douglas

Registered Dietitian
Nutrition Authority pllc

Results like these don't take a year to show up. Most clients see measurable improvement within the first 90 days. If you want to see what's possible for your practice, we'll run a free denial assessment and show you exactly where the revenue is leaking.

Get Your Free Denial Assessment Free analysis · No commitment · See your revenue potential

Support Center

Frequently Asked Questions About Denial Management Services

Denial management services are specialized revenue cycle services that identify, analyze, and resolve denied insurance claims for healthcare providers.

Good denial management also prevents future denials by fixing root causes, whether that's a workflow issue, coding gap, or documentation problem.

The three main types are:

Hard denials — Can't be reversed
Soft denials — Temporary and fixable
Clinical denials — Question medical necessity

Missing or incorrect patient information
Lack of prior authorization
Invalid procedure codes
Services not covered
Timely filing deadlines missed

90% of these denials are preventable.

Soft denials: 24-48 hours to correct and resubmit.

Clinical denials: 30-45 days for first-level appeals, 60-90+ days for escalations.

Industry research puts the average cost around $118 to $181 per appeal when factoring staff time and overhead.

Prevention costs pennies compared to fighting denials afterward.

Verify eligibility before every visit
Confirm prior authorizations are active
Use certified coders
Scrub claims before submission
Track your denial patterns

Rejection: Happens before processing — format issues. Quick fixes.

Denial: Happens after adjudication — requires appeal or resubmission.

Outsourcing makes sense when denials are piling up, write-offs are climbing, or you lack specialized expertise.

You get experienced specialists without hiring overhead.

Most see improvement within 90 days:

Denial rates down 50-70%
Revenue recovery of 20-35%
AR days dropping 30-40%

We provide clinical documentation improvement expertise, LCD/NCD policy knowledge, and peer-to-peer review coordination.

Specialized work most billing departments can't handle effectively.

Still have questions about denial management? We're here to help.

Contact Our Team

Denial Management Services That Recover Your Lost Revenue

Numbers That Speak for Themselves

What Is Denial Management in Healthcare?

The Complete Process

Critical Industry Statistics

The Problem

Standard Process

Our Different Approach

Stop Leaving Money on the Table

The Denial Management Crisis in 2026: What Healthcare Providers Must Know

Rising Denial Rates and Payer AI

New CMS Prior Authorization Rules (Effective January 2026)

MedSole RCM stays ahead of these changes.

Types of Healthcare Claim Denials We Resolve

Hard Denials

Soft Denials

Clinical Denials

Technical Denials

Coding Denials

Authorization Denials

Stop Losing Revenue to Claim Denials

Top Causes of Medical Billing Denials

Missing or Incorrect Patient Information

The Challenge

Our Fix

Pro Tip for Intake Teams

Lack of Prior Authorization

The Challenge

Our Fix

Authorization Best Practice

Duplicate Claims

The Challenge

Our Fix

Workflow Improvement

Invalid Procedure Codes

The Challenge

Our Fix

Annual Code Update Protocol

Non-Covered Services

The Challenge

Our Fix

Coverage Verification Script

Timely Filing Exceeded

The Challenge

Our Fix

Filing Deadline Tracker

Medical Necessity Not Established

The Challenge

Our Fix

Documentation Enhancement

Incorrect Modifier Usage

The Challenge

Our Fix

Modifier Quick Reference

Stop Losing Revenue to Preventable Denials

The MedSole RAPID™ Denial Management Process

Review & Root Cause Analysis

Action & Appeal Submission

Prevent Future Denials

Insight & Analytics

Deliver Results

Our Complete Denial Management Services

Healthcare Providers We Serve Across the USA

Physician Practices & Medical Groups

Hospitals & Health Systems

Specialty Clinics & ASCs

Behavioral Health & Ancillary Providers

Why Healthcare Providers Choose Us for Denial Management

Proven Results

48-Hour Turnaround

Certified Expertise

Technology + Human Judgment

Complete Transparency

HIPAA Compliance & Security

Advanced Denial Management Technology & Automation

Denial Prediction Engine

Automated Appeals Workflow

Real-Time Analytics Dashboard

The Results Our Denial Management Clients Achieve

Performance Metrics

The Denial Management Crisis in 2026:
What Healthcare Providers Must Know