Which denials to work first

A queue of denials worth $34,200? One AR seat works them in this order for $1,700/month, flat. Book 20 minutes · Billing company? Add capacity

1. Clerical — the claim was fine, something was typed wrong — $12,500

Highest-yield work in the building. Nothing clinical is in dispute; a field was wrong, and a corrected claim usually pays. One person can clear a lot of these in a day.

• CO-16 Claim lacks information or has a submission error — $12,500. Read the RARC remark code attached to the denial — CO-16 alone is not actionable and the remark is where the actual reason lives

2. Coverage — wrong payer, wrong plan, or another policy exists — $4,100

The money usually exists somewhere; it is at a different payer or under a different policy. Needs a phone call and an eligibility check, and is time-sensitive because the other payer has its own filing window.

• CO-22 May be covered by another payer — $4,100. Call the patient before you call the payer. They can usually resolve the COB record themselves in one phone call, and the payer will not update it on your say-so

3. Clinical or coding judgement — appealable with documentation — $6,400

Winnable where the note supports it, and unwinnable where it does not. Needs somebody who can read the record, so it is the most expensive hour to spend and worth spending on the largest balances first.

• CO-50 Not deemed medically necessary — $6,400. Find the payer’s own coverage policy, the LCD or NCD for Medicare, and read what it actually requires — appeals that do not quote the policy mostly fail

4. Authorization found after the service — $8,000

Frequently unappealable, because the service already happened and the payer was never given the chance to say no. Worth a retro-authorization request on the big ones; the lesson is upstream, not in the appeal.

• CO-197 Prior authorization absent — $8,000. Pull the authorization record and compare four things against the claim: the CPT code, the units, the date range and the rendering provider

5. Timely filing — $3,200

Recoverable only where you can produce proof the claim arrived on time — the clearinghouse acknowledgement, not a note in your system. With that proof these reverse routinely. Without it, this pile is a write-off and working it is wasted labour.

• CO-29 Time limit for filing has expired — $3,200. Check whether you can prove timely submission: a clearinghouse acceptance report with a date inside the window will overturn many of these

6. Contractual or statutory — not money — $9,000

A contractual adjustment is not a denial. Chasing these is pure waste, and moving one to the patient is a contract breach. Post them and stop looking at them.

• CO-45 Charge exceeds the fee schedule — $9,000. Compare the allowed amount against your contracted rate for that CPT. If they agree, post the adjustment and move on

How this is ordered

By what kind of problem each denial is, not by a recovery percentage. We have no outcome data by code across a client base, so a percentage here would be invented — and it would be the most-quoted number on the page. A wrong diagnosis pointer and a timely-filing denial are not the same bet, and that difference is a fact about the code rather than a prediction about your practice.