Turning Claim Denials Into Revenue Opportunities
Outsource Denial Management Services Without Disrupting Your Billing Team
Almost all of the claims that get rejected never get a second chance. Insurers under the ACA marketplace rejected 19% of in-network claims in 2024, while only less than 1% of the rejections were actually appealed. Insurers under Medicare Advantage rejected 4.1 million prior authorization in 2024 (7.7%) but only 11.5% were appealed, and 80.7% of those appeals were reversed.
When you outsource denial management service, a specialized recovery team is hired while keeping everything else intact – no changes made to EHR, clearinghouse, and in-house personnel. Your biller continues sending claims. We handle what your staff does not have time to do anymore: understanding why payers deny claims, creating appeal letters, and resolving issues to prevent repeat denials.
- Dedicated denial recovery team
- Payer-specific appeal playbooks
- Weekly denial analytics shared
- Works inside existing systems
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Medicare Advantage appeals overturn 81%; only 11.5% appealed.
Denial Management Services That Recover Revenue Payers Withheld
Resilient Medical Billing Services provides denial management services in USA for doctors’ offices, hospitals, and specialty groups. Our experienced certified billers, coders, and appeal team identify the exact reason behind a claim denial, create compelling payer appeals within the time limit provided by payers, and correct mistakes to prevent future denials.
- Root-Cause Analysis
- Appeal Specialists
- Payer-Specific Playbooks
- Denial Analytics
- Faster Recovery
How We Recover Denied Revenue in Five Stages
Our denial management process begins with a look back and ends with prevention. Each stage has a clear owner and output, so you see what was recovered and why.
Denial Data Pull
We gather twelve months of remittances and rejection reports, with the standard adjustment and remark codes attached to each denial.
Root-Cause Sorting
Each denial is classified as a front-end, coding, authorization, credentialing, medical necessity, or payer error and which fixes will pay off first.
Queue and Appeal Setup
Denials are ranked by dollar value and filing deadline. We prepare payer-specific appeal templates and gather the supporting documents.
Recovery Sprint
We work aged denials first, while appeal windows are still open, and track every submission to a final decision for faster claim resolution and recovery.Â
Prevention Loop
Findings go back to registration, coding, and clinical teams. Monthly reports show which causes are shrinking and which payers need escalation.
Curious How Much Denied Revenue Is Still Recoverable?
Share a recent denial report and receive a recovery estimate from our appeal specialists.
Claim Denial Management That Stops Revenue Leaks at Every Stage
Denials usually don’t originate from where they have been found. A denial on a remittance can always be linked to scheduling, coding, authorization, or behavior of the payer. We begin our denial management program at its source; we reverse the denial and rectify the mistake made. Each denial is sorted by cause, owner, and deadline, so recovery work and prevention work happen together.
Hospital Denial Management and Support for Every Care Setting
Denial patterns differ between a solo practice and a health system. Our hospital denial management and physician programs adapt to your size, payer mix, and workflow.
Physician Practices
Eligibility, modifier, and authorization denials, with weekly work queues and appeal support for solo and group practices.
Hospitals and Health Systems
Inpatient medical necessity, authorization, and DRG denials, with appeal packets built with your clinical documentation team.
Specialty Groups
High-cost procedures, imaging, and drugs that trigger prior authorization and medical necessity denials.
Ambulatory and Urgent Care
High-volume claims where small registration and coding errors multiply into a large denied balance.
Denials in US Medical Billing: What 2026 Federal Data Reveals
Payer Prior Authorization Data had to be posted for the first time in 2026, while CMS posts Denial Data related to Marketplace Plans. They provide insights into which claims are denied and which appeals succeed.
| Payer Type | Denial Rate | Appeal Outcome |
|---|---|---|
|
Medicare Advantage (2024 requests)
|
7.7% of prior authorization requests denied in full or part
|
11.5% appealed; 80.7% partially or fully overturned
|
|
Traditional Medicare (2024 requests)
|
22.9% of just over 625,000 requests denied
|
Not reported for 2023 or 2024
|
|
Medicare Advantage, Medicaid managed care, and ACA (2025 public metrics, standard requests)
|
12%, 14%, and 18% denied, respectively
|
67%, 47%, and 43% overturned on appeal
|
|
ACA Marketplace claims (2024)
|
19% of in-network claims denied
|
Fewer than 1% appealed; insurers upheld 66% of challenges
|
Success rates of appeals are high enough to make it worthwhile, but few organizations try. Furthermore, starting from January 1, 2026, covered payers will have to give a justification for each denied prior authorization. This information helps us in filing our appeals based on that justification.
Most Denials Start Before the Claim Is Filed
Insurers who deny claims based on administrative issues make it clear that many of these denials are preventable. Administration issues made up 25 percent of in-network denials; excluded services, 13 percent; prior authorization, 9 percent; members not enrolled in plan, 7 percent; and medical necessity or plan benefit limitations, 5 percent. Our coding denial management services and front-end controls target each cause.
Administrative errors (25%)
Claim scrubbing for missing or mismatched data, and clean-up of recurring registration mistakes.
Excluded services (13%)
Benefit checks before the visit, and patient notification when a service is likely not covered.
Missing authorization (9%)
Authorization tracking tied to the scheduled service, date, and provider.
Member not covered (7%)
Eligibility rechecks at the visit and before claim submission.
Medical necessity and benefit limits (5%)
 Coding and documentation review that links diagnoses to the services billed.
Provider enrollment gaps
Credentialing status checked before billing, so claims are not denied as out of network.
Denial Management Across All Specialties
There are various types of denials depending on the specialty, ranging from authorization denial to modifier denial. Resilient MBS employs specialists familiar with your payor’s rules, thus handling your denials based on actual denial criteria. Resilient MBS offers tailored medical claims denial management for each specialty, including:
Primary Care and Internal Medicine
Modifier -25 conflicts, preventive visit denials, and E/M level disputes.
Cardiology
Imaging and procedure authorizations, medical necessity documentation, and bundling edits.
Orthopedics
Global period conflicts, implant and DME denials, and authorization lapses on surgical cases.
Oncology
Drug billing, step therapy requirements, and medical necessity appeals for high-cost treatments.
Radiology and Emergency Medicine
Emergency medicine accounts for 41%, while radiology represents 29% of Out-of-network.
Behavioral Health
Medical necessity reviews, time-based code denials, and Medicaid eligibility lapses.
Fewer Delays, Fewer Surprises: How Resilient MBS Works Differently
Not all denial management companies work the same way. Here is how our approach compares with a typical vendor.
| Typical Vendor | Resilient MBS | |
|---|---|---|
|
Scope |
Resubmits denied claims
|
Traces and fixes the root cause
|
|
Appeals
|
Standard letters
|
Payer-specific arguments with clinical evidence
|
|
Deadlines
|
Tracked informally
|
Appeal windows calendared by payer and account
|
|
Payer reasons
|
Generic denial codes
|
Specific stated reasons used to guide appeals
|
|
Prevention
|
Not included
|
Findings sent back to registration, coding, and clinical teams
|
|
Reporting
|
Recovered totals only
|
Denial rate by cause, payer, and provider, plus overturn rates
|
|
Systems
|
May require a separate platform
|
Works inside your existing EHR and clearinghouse
|
FAQs
The entire process of finding out why the claims have been denied, fixing them and then appealing them to avoid such future rejections, all form the core of this procedure.
Denials point to areas where the process fails. Proper eligibility in the front end, proper coding and claims keep denials at bay. Payment posting and A/R activities identify denials. Denial management completes the cycle through revenue recovery and feedback to all stages.
This situation arises where the payer rejects a claim due to the absence of enrollment, credentialing, or association between the provider and the billing entity on the date of service. This denial can be prevented by verifying the enrollment status prior to billing.
Deadlines vary by payer and denial type. Denials involving Medicare must be appealed within 120 days, whereas commercial plans have their own time frames. Every deadline is put into our calendar as soon as we enter the denial.
Certainly. We handle denials that come through Medicare, Medicare Advantage, Medicaid, and private insurers through their respective appeal processes. From January 2026, all prior authorization denials made by MA and Medicaid plans must be accompanied by specific reasons, which we will utilize in appeals.
You receive monthly reports covering denial rates by cause, payer, and provider, appeals filed, overturn rates, dollars recovered, and the prevention actions completed.
Stop Writing Off Revenue You Have Already Earned
Speak with a Resilient MBS denial specialist and receive a custom recovery plan for your practice.
