Denial Management
The problem
Denials get worked reactively, one at a time, until the team runs out of hours — and then they get written off. The industry quietly accepts that a meaningful share of denied claims are simply abandoned. But most denials are preventable, and the ones that aren't are usually appealable. The money left on the table isn't a few edge cases; for many practices it's the difference between a healthy margin and a struggling one.
How NuGenera Health does it
We work denials two ways at once. Downstream, every denial is triaged, categorized by reason code, and worked to resolution — appeal, correction, or documented adjustment — within defined timeframes so nothing ages into a write-off. Upstream, we analyze denial patterns to find and fix the root cause: a payer edit we can preempt, a documentation gap to close, a coding habit to correct, an eligibility step that's being skipped.
Appeals are prioritized by recoverable value and deadline, with payer-specific appeal packages assembled and tracked to a decision. We don't just submit an appeal and hope; we follow it through the payer's process and escalate when it stalls.
First-pass resolution rate is the KPI that tells you whether denial work is actually improving. We report it monthly, along with denial rate and overturn rate, so the trend is visible rather than anecdotal.
Key capabilities
- Denial triage and categorization by reason code
- Payer-specific appeal package assembly and submission
- Root-cause analysis and upstream prevention
- Denial-pattern detection across payers and services
- Underpayment identification during denial review
- First-pass resolution and overturn-rate reporting
Technology that supports it
Denial-pattern detection aggregates reason codes across payers to surface systemic issues, not just individual claims. Structured worklists ensure every denial is touched within its timeframe, and analytics tie denials back to the upstream step — eligibility, authorization, coding, or submission — where they can actually be prevented.
Frequently asked questions
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