Why denials keep coming back
Most clinics “work denials” but don’t prevent repeats. That’s why the same denial shows up every week. The fix is an operator loop:
Categorize → Assign ownership → Fix the source → Lock into SOP → QA sample → Report weekly.
When you do this weekly, denials stop being a fire and become a system improvement engine.
Sprint setup (60 minutes)
- Pull denials for the last 2–4 weeks.
- Create 8–12 categories (eligibility, bundling/CO‑97, missing info, timely filing, coding/modifier, medical necessity, duplicate, other).
- Rank by count and by dollars. Pick the top 2 as sprint targets.
- Assign one owner per category (front desk / billing / coding / provider lead).
Fast tip (not obvious): pick one denial category that is high frequency and one that is high dollars
This prevents the common mistake of chasing only high-dollar denials while the high-frequency “small” denials keep draining time.
Root-cause mapping (the part clinics skip)
For each target denial, answer one question:
Where did the error start? (Front desk / Provider documentation / Coding / Claim edits / Payer rule)
| Denial | Common true root cause | Preventive fix |
|---|---|---|
| Eligibility | Missing relationship/subscriber DOB, wrong member ID, no pre-visit eligibility | Insurance capture script + eligibility check step + “missing fields” rejection queue |
| CO‑97 / bundling | Service not distinct OR missing modifier documentation | Bundling decision tree + template prompt for distinct service note |
| Missing/invalid info | NPI/taxonomy/location mismatch in PM | Provider master file audit + clean claim checklist item |
| Timely filing | Claims stuck in work queue | Daily submission SLA + “stuck claims” dashboard |
Operator move: every fix must create a new habit (SOP/checklist), not “try harder.”
QA sampling (how you make it stick)
QA is the glue. Without it, changes decay.
- Sample 10 claims/day for 5 days against your new rules.
- If a miss repeats twice → the SOP is unclear → rewrite it.
- Publish the top 3 misses weekly and train on them (10 minutes).
Hack: Track “repeat miss rate” instead of “denials worked.” Repeat misses tell you where the system is weak.
Weekly one-page report template
This is how owners and clinicians stay confident without drowning in details:
- Denial mix: top 3 categories + trend.
- What changed: the one SOP/checklist update.
- What moved: AR bucket movement.
- Blockers: what’s stuck + owner + due date.
When leaders see consistent reporting, trust rises quickly.
Implementation checklist (copy/paste)
- Choose the KPI you want to move.
- Implement one workflow change (SOP + checklist).
- QA sample 10 items/day for 5 days.
- Publish a 1‑page weekly report: KPI, blockers, next action.
Educational resource only — not legal/medical/billing advice.