Denials eat margin and tie up staff. The only way to get ahead is to fix the causes and appeal the ones that shouldn’t have been denied. Doing one without the other leaves money on the table.
Why claims get denied
Common reasons: face-to-face missing or outside the window, order-to-note mismatch, missing or incorrect documentation, eligibility or auth issues, and coding errors. Pull a sample of your denials and code the reason. If 40% are “missing F2F documentation,” that’s your first project,intake and chart review before submission. If it’s “auth not on file,” that’s verification and workflow. You can’t fix what you don’t categorize.
Appeal process
Payers have a set window for appeals (often 60 days from the denial). You need the denial notice, the supporting documentation, and a clear letter that states why the claim should be paid. Include the chart, the face-to-face, and the order. Be specific. Generic “please reconsider” letters don’t work as well as “the F2F encounter dated X meets the 90-day requirement; see attached.” Track appeal success rate by reason so you know which battles are worth fighting.
Prevention
Every denial you prevent is better than one you appeal. Build a pre-bill check: F2F present and in window, order matches note, auth on file, codes aligned. Some agencies do a quick review on every chart before it goes to billing. It takes time upfront but cuts denials and appeal workload. We have a denial appeal checklist you can download: reason codes, appeal letter outline, and a short pre-bill checklist.