Denial Management Services for U.S. Healthcare Providers. Medical Groups. Healthcare Organizations.

MediFlows Billing Solutions provides denial management services for U.S. medical practices. We read every denial on your remittances, correct or appeal it before the payer’s deadline, and fix the front-desk or coding step that caused it. We start with a 30-day denial audit that names your top five denial causes and the dollars in each, delivered by day 7.

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WHAT TO EXPECT

What denial management services should hand you in the first month

A denial management service is only worth paying for if you can see what it’s doing. In the first 30 days you should get four things in writing: a list of what’s denied, what it’s worth, who caused it, and what’s been sent back to the payer.

The 30-day onboarding schedule

Timeline	What Happens	What You Receive
Day 1	Kickoff & Data Access We start with a kickoff call, establish read-only access to your practice management system and clearinghouse, and review the last 90 days of 835 remittances.	A customized list of the payers and deadlines we’ll track for your practice.
Day 7	Denial Audit Complete We analyze denial patterns, identify recurring issues, and quantify the financial impact of your biggest denial categories.	A concise, one-page report detailing your top 5 denial causes, dollars at stake, and the person responsible for each fix.
Day 14	Denial Worklist Goes Live Every open denial is organized by deadline, with priority given to claims approaching their filing or appeal deadlines.	Corrected claims and initial appeals submitted for the most urgent denials.
Day 30	First Monthly Performance Report We review work completed, financial recovery, outstanding appeals, and opportunities to improve your denial management process.	A monthly report covering denials worked, dollars recovered, pending appeals, and the process change most likely to reduce your largest denial category.

A lot of denials are more about administrative issues than actual clinical reasons.

The best public data on denials now comes from insurers’ own filings. KFF’s March 2026 analysis of CMS Transparency in Coverage data for 2024 HealthCare.gov plans found insurers denied 19% of in-network claims and 37% of out-of-network claims. Denial rates swung from 3% to 36% depending on the insurer.

When KFF looked at the stated reasons, 36% of in-network denials were filed under “Other”, 25% were administrative, 9% were for missing prior authorization and only 5% were for medical necessity. Fewer than 1% of denied claims were appealed.

So only about one denial in twenty was a question of whether the care was needed. Most were paperwork, eligibility and authorization problems. Those can be fixed, and most can be prevented.

The denial codes that carry most of the recoverable money

Every denial on a remittance carries a group code (who owes it) and a reason code (why). Here’s where the common ones start and who owns the fix. Each code links to our full guide.

Denial Code	Plain Meaning	Where It Starts	Who Owns the Fix
CO-16	Missing Information or Billing Error	Registration or charge entry	Front Desk or Biller
CO-22	Another Payer May Be Primary	Registration	Front Desk, Then Biller
PR-27	Coverage Ended on Date of Service	Eligibility not checked	Front Desk
CO-109	Claim Sent to the Wrong Payer	Registration	Front Desk
CO-197	Prior Authorization Missing	Scheduling	Authorization Staff
CO-97	Service Bundled Into Another Paid Service	Coding (often an NCCI edit)	Coder
CO-50	Medical Necessity Not Established	Documentation and diagnosis coding	Provider and Coder
CO-252	Additional Records Required	Payer request	Biller
CO-29	Filing Deadline Missed	Billing backlog	Billing Manager
CO-45	Charge Exceeds Contracted Rate	Your fee schedule	Usually No Corrective Action Typically a contractual adjustment

Outsourcing credentialing services for providers makes the most sense when you’re adding providers, opening a new location, or have applications stuck for months. If you have one provider and a few payers, in-house can work. Just keep a calendar of every CAQH, license and revalidation date.

The risk of denial varies depending on the type of payer involved.

Each payer type denies for different reasons and gives you different deadlines. A denial management service that treats them all the same misses money.

Medicare fee-for-service.

The rules are written in federal regulation, which makes them predictable. You have 12 months from the date of service to file (42 CFR § 424.44) and 120 days from the initial determination to ask for a redetermination (42 CFR § 405.942). Noridian, a Medicare contractor, states that claims denied for timely filing have no appeal rights. That makes CO-29 the most expensive denial on a Medicare remittance.

Medicare Advantage.

Prior authorization is the main risk. An HHS Office of Inspector General report (April 2022) reviewed a sample of Medicare Advantage denials and found that 13% of prior authorization denials and 18% of payment denials met Medicare coverage rules, meaning they should have been approved. Those are worth appealing. A strong prior authorization process stops many of them from happening at all.

Commercial plans.

Every contract sets its own filing and appeal limits, some as short as 90 days. KFF’s data shows how much insurers differ: in-network denial rates ran from 3% to 36% across companies in the same marketplace. We track the limits payer by payer.

Medicaid managed care.

An OIG report (July 2023) found Medicaid managed care plans denied about 1 in 8 prior authorization requests (12.5%) in 2019, and some plans denied more than 25%. Eligibility also changes month to month, so PR-27 and CO-109 denials are common.

What denial work costs you in-house, with the arithmetic shown

Here’s a worked example for a practice sending 1,000 claims a month. Every input is marked as sourced or assumed. Swap in your own numbers.

Line Item	Financial Value	Source & Calculation
Claims Submitted Per Month	1,000	Assumed
Denial Rate	10%	Assumed Experian Health: 41% of providers reported denial rates at or above this level, according to the cited research.
Denials Per Month	100	Calculated 1,000 × 10%
Cost to Rework One Denial	$25.20	Sourced: MGMA
Monthly Rework Cost	$2,520	Calculated 100 × $25.20
Yearly Rework Cost	$30,240	Calculated $2,520 × 12 months
Annual Cost at Premier’s 2023 Dispute Cost	$68,676 Per year	Calculated 100 denials × $57.23 × 12 months
Average Salary: Billing & Coding Professional	$65,007	Sourced: AAPC 2025 Salary Report
Median Wage: Medical Records Specialists	$50,250	Sourced: BLS U.S. Bureau of Labor Statistics, May 2024

The rework cost doesn’t include the denials nobody worked. KFF’s data shows fewer than 1% of denials get appealed. Every unworked denial is 100% of that claim’s value lost.

Six questions to ask every denial management company

Question	Why It Matters	MediFlows Answer
01 Do you work every denial, or only those above a specific dollar amount?	Some vendors skip smaller claims. Even small unpaid amounts can add up across a practice.	Our Commitment We work every denial, not just those above a specific dollar amount. Our team reviews each denial, identifies the root cause, corrects the issue, and resubmits it to maximize reimbursement.
02 Are second-level appeals included, or do they cost extra?	First-level appeals may require less work. Later appeal levels can involve additional documentation and effort.	Included in Our Service Second-level appeals are included, with no extra fee. We handle the full appeal process through resolution.
03 Will you work on denials from before we started? Is there an extra fee?	Older unresolved denials can represent substantial outstanding revenue, although deadlines may affect recovery options.	Existing Denials Welcome Yes, we can work on pre-existing denials from before we started. There is no extra fee for handling those denials.
04 Do you report denial causes by owner, such as front desk, coding, and payer?	Without clear ownership, the same denial issues can recur month after month.	Actionable Reporting Yes. Every report sorts denial causes by who owns the fix.
05 What reports do we receive, and how often?	Regular reporting gives your practice visibility into progress, outstanding appeals, and financial recovery.	Ongoing Transparency Day 7 denial audit, followed by a monthly report, as outlined in our 30-day schedule.

services include

What our denial management services include

Function	What It Means for You
Daily Denial Capture	Every denied line on every 835 and EOB is logged the day it posts
Code and Remark Reading	Group code, reason code, and remark code are read together so nothing is misfiled
Root-Cause Tagging	Each denial is tagged by where it started: front desk, coding, payer, or contract
Corrected Claims	Fixable errors are corrected and resubmitted
Medicare Reopenings	Clerical errors are fixed through a reopening instead of a full appeal
First-Level Appeals	Written appeals are submitted with the records and documentation that support the claim
Second-Level Appeals	Second-level appeal submissions and follow-up for eligible denied claims
Records Requests	CO-252 requests are answered before the payer’s deadline

Function	Why It Matters to You
Coordination of Benefits	CO-22 denials are routed to the right primary payer
Authorization Follow-Up	Retro-authorization requests are pursued where the payer allows them
Underpayment Checks	Paid amounts are compared with your contracted rates to identify potential underpayments
Deadline Tracking	Filing and appeal limits are tracked payer by payer so important deadlines are not missed
Payer Follow-Up Calls	Calls are made on claims with no response or unresolved payer status
Monthly Denial Report	Denials, dollars, recoveries, and open appeals are reported by cause and payer
Prevention Plan	One process improvement each month targets the biggest denial group

Specialty and Nationwide coverage

We work denials for practices in all 50 states. Denial patterns change by specialty: therapy practices see more frequency-limit denials (CO-151), surgical practices see more bundling denials (CO-97), and behavioral health sees more authorization denials (CO-197). The day 7 audit shows which pattern your practice has, so we don’t guess.

New practices often see CO-B7 denials because a provider started seeing patients before their payer enrollment was active. That’s a credentialing and payer enrollment problem, and fixing the enrollment date is usually faster than appealing each claim.

Switching from in-house billing or another vendor

Switching is where denials get lost. Old denials sit in the previous team’s worklist while their appeal deadlines run out. Here’s how we handle it:

Freeze nothing. Your current team keeps submitting new claims until handover day.
Pull 90 days of remittances so every open denial is listed, not just the ones someone remembers.
Sort by deadline first. Medicare’s 120-day redetermination window and each commercial payer’s limit decide what gets worked first.
Work the backlog separately from new denials, so old money isn’t buried under new work.

For claims that are aged but not denied, see our AR follow-up on aged claims. If you run billing in-house and just want a better process, our guide to denial management for small practices shows how to set up a denial log yourself.

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FAQ’s about the Service

What are denial management services?

Denial management services review every denied claim on your remittances, find the cause, correct or appeal the claim before the payer's deadline, and report which step in your practice caused it so the same denial doesn't come back.

What's the difference between denial management and AR follow-up?

Denial management works claims the payer has refused. AR follow-up chases claims that haven't been paid or answered yet. Most practices need both, because an unanswered claim can turn into a timely filing denial.

How fast can denied claims be recovered?

It depends on the denial. A corrected claim for a CO-16 error can be paid in one payer cycle. An appeal for a CO-50 medical necessity denial takes longer. Medicare must decide a redetermination within 60 days of receiving it.

Can you work denials that are already old?

Yes, as long as the payer's appeal or correction deadline hasn't passed. That's why we sort the backlog by deadline first. Claims denied for timely filing usually can't be recovered.

Which denials can't a billing company prevent?

Denials that start at the front desk, such as wrong insurance, coverage that has ended, or a missing authorization. We can find them, work them and show you the pattern. Preventing them takes a change at check-in or scheduling.

Do you handle Medicare Advantage and Medicaid denials?

Yes. An HHS Office of Inspector General report in 2022 found 13% of sampled Medicare Advantage prior authorization denials met Medicare coverage rules, so these are often worth appealing. Medicaid plans also deny more prior authorizations, and coverage can change month to month.

What reports will I get?

A one-page denial audit by day 7, then a monthly report showing denials received, worked and recovered, appeals pending, and the top causes sorted by who owns the fix.

Do I have to change my EHR or practice management software?

No. We work inside your existing system. Our team works in AdvancedMD, Tebra, eClinicalWorks, DrChrono, NextGen and CureMD.