Cutting preventable denials by 31% across a four-hospital system

Client profile

Organization type

Regional health system

Specialty

Acute care, multi-facility

Scale

4 hospitals, ~$680M net patient revenue

The challenge

Initial denial rate had climbed above 11%, with more than half of denials traced to eligibility, authorization and medical-necessity issues occurring before the claim was ever coded. The system had denial reporting but no operating rhythm to act on it.

The solution

• End-to-end denial management and appeals
• Denial prevention program with front-end intervention
• Coding audit feedback loop
• Payer rule monitoring and edit library

Our approach

1. 1

   Classified 12 months of denial history into actionable root-cause categories.

2. 2

   Deployed dedicated front-end clearance and authorization pods for the highest-denial service lines.

3. 3

   Built payer-specific pre-submission edits into the claim scrubbing workflow.

4. 4

   Established a weekly cross-functional denial council with owner-assigned corrective actions.