Denial management and A/R follow-up. Root cause first, then the work-down.
For the practice manager or CFO looking at aging A/R and a denial queue that keeps growing. Every denial is sorted by root cause, aged balances are worked biggest dollars first, appeals go out senior-reviewed, and the top causes are fixed upstream so the same denial stops coming back.
Six quick questions, about four minutes, no PHI required. Rather talk it through? Talk to a senior partner about denials.
Then recovery.
Two problems that feed each other. One team working both.
Unworked denials become aged A/R, and aged A/R hides the denials that caused it. We run denial management and A/R follow-up as one function: classify the denial, work the balance, appeal where the dollars justify it, and send the root cause back to the team that can stop it. You can bring us in for denials and A/R only, or as part of full revenue cycle management.
Five aging buckets. Five different moves.
A/R aging breaks your outstanding payer and patient balances down by days since service. Old A/R has a lower chance of collection, so each bucket gets its own action, and the oldest dollars get a senior decision instead of a default.
Wait
Claim is inside normal payer processing. Watch for rejections, do not chase.
Light touch
Claim status check by portal or call. Confirm it is on file and moving.
First call or appeal
Payer follow-up call. Denied lines move into the root-cause and appeal workflow.
Escalation
Escalated with the payer, with timely-filing limits tracked per payer.
Senior partner review
Decision on each balance: keep pursuing, or a documented write-off recommendation for your sign-off.
We age from date of service, not date of posting. Posting-date aging restarts the clock every time a claim is touched, which makes old A/R look younger than it is. More in our A/R aging glossary entry.
Biggest dollars first. Every cycle.
A/R follow-up fails when it is worked by claim count. We work it by dollar value, on a cadence set per payer, with a written record of every touch.
Dollar-weighted prioritization
Work queues are ranked by balance size, account age and payment likelihood, so effort goes where it pays and not into accounts that will never collect.
Payer follow-up and claim status
Follow-up is scripted by line of business and run on payer-specific call and portal rhythms, not a generic 30/60/90 schedule, and tracked to a written cadence.
Self-pay balances and insurance discovery
Some accounts marked self-pay have coverage the front desk never captured. Self-pay accounts under 365 days from service run through a monthly discovery sweep, every hit is confirmed with a 270/271 eligibility check, and confirmed coverage moves back into billable A/R.
Payer A/R and patient A/R, kept separate
Payer A/R needs appeals, status calls and contract enforcement. Patient A/R needs statement cadence and payment plan offers. Different workflows, so they are run and reported separately.
Every denial gets a root cause, not just a status.
The reason code tells you what the payer did. It is the first sentence of the story, not the last. Before anything is appealed, each denial is classified into one of five lanes, because each lane is fixed by a different team.
Clinical
Medical necessity and documentation. The service was billed, but the chart or the payer policy did not support it.
Eligibility
Coverage terminated, the wrong payer billed, or another payer primary under coordination of benefits.
Authorization
Precertification absent, expired, or not matching the units, dates or codes billed.
Coding
Diagnosis inconsistent with the procedure, bundled services, or modifier problems.
Registration
Missing or invalid claim information, demographic errors and duplicate submissions.
Fewer denials, not faster appeals.
The top five root causes each month feed upstream fixes at the front desk, in coding and in authorization. That is how the denial queue gets shorter instead of just getting worked faster.
Common CARCs, the lane that owns them, and the fix.
Claim Adjustment Reason Codes are the X12 standard codes payers attach to claim lines in the 835 remittance. Each one maps to a lane, and each lane has a prevention move. The full list is in our CARC code reference.
| Code | Description | Lane | Prevention move |
|---|---|---|---|
| CARC 16 | Claim lacks information needed for adjudication | Registration | Pre-submission validator checks claim-line modifiers, units, place of service and attachments against the payer rule pack. |
| CARC 18 | Exact duplicate claim or service | Registration | Duplicate check against recent claims before submission. Most CARC 18s are not appealable. |
| CARC 22 | Care may be covered by another payer (COB) | Eligibility | Coordination-of-benefits check at intake, with secondary verification for chronic patients. |
| CARC 27 | Expenses incurred after coverage terminated | Eligibility | Real-time eligibility at every visit. Catch the term date at intake. |
| CARC 109 | Claim or service not covered by this payer | Eligibility | Real-time eligibility and active-coverage check, plus coordination of benefits at intake. |
| CARC 197 | Precertification, authorization or notification absent | Authorization | Authorization tracker linking auth number, units, date span and service codes to the claim at submission. |
| CARC 11 | Diagnosis inconsistent with the procedure | Coding | DX-to-CPT validity check at coding, with the NCCI edit table applied. |
| CARC 97 | Benefit included in another service | Coding | NCCI edit and bundling rules applied at coding. Modifier 59 only with documentation support. |
| CARC 50 | Service not deemed a medical necessity | Clinical | LCD and NCD policy check before submission. Medical necessity documented in the chart at the time of service. |
| CARC 29 | Time limit for filing has expired | Timely filing | Claim-aging alerts well ahead of each payer's timely-filing window, tracked per payer. |
Read the chart before writing the appeal.
The move after a denial is to read the chart and the authorization, not to file the appeal. Some denials are corrected and resubmitted. Some are appealed. A few are not worth pursuing, and that decision is written down.
Read the remit
CARC and RARC from the 835 identify what the payer did and on which line.
Read the chart and auth
Documentation, authorization and eligibility are checked against the denial before anything is written.
Decide the path
Correct and resubmit, appeal, or recommend write-off. The decision carries a reason code.
Written appeal pack
High-dollar lanes get a written appeal pack. Every appeal is senior-reviewed before it goes out.
Close the loop
Outcome tracked, and the root cause routed back to coding, eligibility or the front desk.
Medicare fee-for-service appeals follow the CMS appeals process, which starts with a redetermination by the Medicare Administrative Contractor. Other payers set their own appeal requirements, so each pack is built to the payer, not to a template.
Catch the denial before the claim leaves.
Recovery work pays for itself only once. Prevention keeps paying. The same root-cause data that drives appeals also drives a check at the submit gate.
Every claim line scored. Before submission.
Our denial prediction engine scores each claim line for denial risk, the most likely CARC and the recommended action, against more than 80 tracked CARC patterns. See the denial prediction engine.
Fix it, route it, or log it.
- Auto-correct, only on deterministic patterns where the fix is unambiguous, such as a missing referring NPI. Every correction leaves an audit-trail entry.
- Specialist route for judgment calls like medical necessity or documentation gaps. These never auto-correct.
- Root-cause loop: when a denial posts, the cause feeds back to coding, eligibility or credentialing.
- Learn more: AI for denial prevention and the CARC code reference.
What you see every month.
A monthly CFO scorecard pulled from your PMS, walked line by line by a senior partner. Write-offs and adjustments are governed, not automatic.
Denials and A/R, answered plainly.
Can you work A/R that is already over 90 or 120 days old?
Yes. Aged A/R is worked by dollar value, biggest balances first. Claims in the 91-120 day bucket are escalated with the payer. Anything over 120 days gets a senior partner review that decides, claim by claim, whether to keep pursuing it or recommend a write-off. Timely filing limits are tracked per payer, with claim-aging alerts well ahead of each window. We do not promise a recovery figure before we have read your aging report.
How do your appeals work?
Root cause first. We read the CARC and RARC on the remittance, then the chart and the authorization, before anything is written. If the claim can be corrected and resubmitted, it is. If it needs an appeal, the high-dollar lanes get a written appeal pack, and every appeal is senior-reviewed before submission. Medicare appeals follow the CMS appeals process, which starts with a redetermination by the Medicare Administrative Contractor.
Which denials do you work?
All of them, sorted into five root-cause lanes: clinical (medical necessity and documentation), eligibility (terminated coverage, wrong payer, coordination of benefits), authorization (precertification absent or mismatched), coding (diagnosis and procedure conflicts, bundling) and registration (missing or invalid claim information, duplicates). Each lane is fixed by a different team, so the lane decides who gets the feedback.
Do we need to change our EHR or practice management system?
No. We work inside your existing EHR and PM system and do not require a system change to engage. Access is provisioned during onboarding, and we sign a BAA at the start of the engagement.
Will you write off our old balances?
Only with your sign-off. Nothing is auto-written off. Every adjustment carries a reason code, and balances over 120 days get a senior partner review for write-off versus continued pursuit. When a write-off is recommended, you see the dollar value and the reason before it is posted.
How do we get started?
Run the free denial audit: six quick questions, about four minutes, no PHI required, and a 2-page PDF report. If you would rather start smaller than full RCM, we take on focused engagements such as denial management only or A/R cleanup only.
How is pricing quoted?
In writing, by a senior partner. Tell us your specialty, monthly claim volume, EHR or PM system and payer mix, and mention aging A/R or rising denials in the message box. You get a written quote within one business day, locked for the contract term. We do not publish a rate, because a fair price depends on your book.
Start with the free denial audit.
Six quick questions, about four minutes, no PHI required. You get a 2-page PDF with a leakage estimate, a peer benchmark and the top three opportunities for your practice. When you are ready, a senior partner sends a written quote.
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