Denial Management Services

Denial Management That Prevents Revenue Loss Before It Starts

At IntegraRCM, denial management isn't just about fixing rejected claims—it's about stopping preventable denials from ever entering your revenue cycle.

We help hospitals, physician groups, and specialty clinics shift from reactive denial recovery to data-driven denial prevention, ensuring that services delivered translate into revenue collected. In an environment where payer scrutiny is increasing and staffing capacity is shrinking, denial management must function as a strategic control point—not a back-office clean-up task.

The 2025 Reality: Why Traditional Denial Management Is Failing

Healthcare organizations entered 2025 facing a structural imbalance that requires a new approach:

Rising Payer Automation: Denial rates continue to rise, driven by AI-driven edits and tighter medical-necessity interpretations.
Unsustainable Costs: The cost to resolve a single denial now ranges from $25 to $181, often exceeding the value of the claim itself.
The Resource Gap: A majority of denials are never appealed because RCM turnover rates (approaching 40%) have made labor-heavy workflows unsustainable.
Preventable Leakage: Organizations spend millions chasing denials that should never have occurred, while revenue compounds quietly upstream.

Why "Recovery-Only" Is No Longer Enough

Back-end appeals alone cannot keep pace with modern payer behavior. Best-in-class management now requires three-pillar integration:

Front-End Prevention

Eligibility, authorization, and registration accuracy.

Mid-Cycle Alignment

Documentation integrity, modifier accuracy, and payer-specific rules.

Back-End Intelligence

Trend analysis, payer behavior tracking, and appeal optimization.

For RCM leaders, denial management must be embedded across the entire revenue cycle—not isolated to A/R follow-up.

IntegraRCM Denial Management Workflow

Prevention & Clean
Claims

Submission
Monitoring

Denial Capture &
Classify

Investigation &
Action

Reporting &
Improvement

IntegraRCM's denial-management workflow, from prevention through resolution and continuous improvement.

Before & After Impact

Metric	Before IntegraRCM	After IntegraRCM
% of claims denied on first submission	15–20%	↓ 40–60% over 12 months
Days in AR attributable to denials	Extended cash-flow delays	Shortened; improved reimbursement timeline
Staff time on appeals/rework	Significant administrative burden	Reduced; focus on clean claims
Write-offs due to no appeals	Frequent	Significantly fewer; higher recovery
Visibility into denial trends	Limited / reactive	Real-time dashboards

Case Study: Specialty Clinic Denial Turnaround

Client: 55-physician multi-specialty clinic (cardiology, orthopaedics, imaging)
Challenge: Elevated denial rates (~18%) for high-end imaging & surgical procedures; appeals backlog; limited visibility.

Front-end audit of documentation, authorization, and coding workflows.
Denial-capture database with weekly reporting.
Dedicated appeals team for high-value payers.

Results (within 9 months): Denial rate 18% → 8%; denial-related AR days 45 → 22; recovery of write-offs ↑30%; actionable monthly insights improved payer negotiations.

Average Denial Reduction

0×

Faster Appeal Turnaround

Revenue Recovered from Write-Offs

Engagement & Pricing Models

Model	Description	Suitable For
Per-Denial Case Fee	Fixed fee per denied claim (investigation, appeal, resubmission)	Clinics with moderate denial volume
Dedicated Team / FTE Model	Embedded denial-management team handling prevention, capture & resolution	Hospitals, health systems, high-volume specialties
Hybrid Model	Base retainer for ongoing support + per-case fee for overflow/complex appeals	Mid-size multi-site groups with fluctuating volume

Onboarding includes a 12-month denial audit, baseline metrics, workflow gaps and payers of concern. SLAs define targets (denial reduction, appeal TAT, cost per denial). Engagements scale by volume, specialty mix and payer complexity.

What Clients Can Expect

Clear reduction in rejected claims and more clean-claims submitted.
Enhanced cash flow via timely appeals and resubmissions.
Front-end alignment (eligibility, authorization, coding) to minimise downstream denials.
Monthly KPIs: denial rate, recovery amount, denial-related AR days, root-cause trends.
Audit-ready documentation and payer-interaction records.
Strategic partnership, an extension of your revenue team.

Most organisations see measurable improvements within the first quarter, with sustained gains over 9–12 months.

Frequently Asked Questions

Q1. What types of denials do you handle?

Eligibility/coverage, missing authorization, coding/documentation errors, payer policy denials, DRG downgrades, and timing issues.

Q2. How do you decide reversible vs write-off denials?

We classify each denial by root cause and payer rule; high-probability recovery cases go to appeal, low-yield write-offs are filtered out early to avoid wasted effort.

Q3. What's your typical appeal success rate?

Varies by payer and specialty, but our clients consistently outperform their baselines due to targeted corrective actions and documentation rigor.

Q4. Do you integrate with our systems (EHR, PM, billing)?

Yes, we connect to standard platforms to capture denials, manage workflow, and produce audit-ready reporting.

Q5. How quickly will we see improvements?

Early gains often appear in the first quarter; major reduction in overall denial rate and AR impact typically arrives within 9–12 months.

Q6. What if our denial volume changes significantly?

Our models scale. Volume shifts trigger a staffing and SLA review to maintain performance without overspend.