Denial management services: claim review and appeals

Denial management services review unpaid claims after payer decisions and address the causes of repeat errors.

Actigy BPO provides scoped triage, corrections, appeal preparation, payer follow-up and root-cause reports. An audit and paid pilot test the queue before expansion. Clinical judgments, coding policy and write-off decisions remain with the client. The work includes tracking deadlines and outcomes, not simply closing tasks.

Denial management addresses a payer's refusal or adjustment and the evidence needed to challenge or correct it. AR follow-up covers a wider set of unpaid balances, including claims still pending and payments not yet matched.

Actigy BPO assigns cases by status and required action. A balance can move between queues as the payer responds. Track the owner and deadline rather than treating every unpaid claim as a denial.

Actigy BPO checks the denial reason, payer policy, deadline and available evidence before preparing an appeal. Some cases need corrected data rather than an appeal. Others require clinical support that only the provider can approve.

Appeal rights and routes vary by payer and claim. Operators do not promise recovery from a reason code alone. Missing records, expired limits and contractual exclusions need explicit client review before further work.

Actigy BPO groups repeat denials by cause and assigns each cause to a named client owner. Coverage errors, missing approvals and coding gaps need different fixes. Reports distinguish cases worked from process changes completed.

The client approves changes to front-desk checks, records and coding rules. Review later claims for the same error. An overturned appeal recovers one claim; it does not show that the underlying problem has stopped.

Actigy BPO can scope the work when client contracts and payer rules allow the proposed access and locations. The client confirms offshore restrictions and disclosure duties before records enter the queue. Location alone does not establish permission.

Payer calls take place during US business hours. Portal work and evidence preparation can use other agreed shifts. Confirm named accounts, permitted data and client escalation coverage before starting the pilot.

Actigy BPO estimates backlog work after reviewing age, payer mix, evidence gaps and deadlines. A fixed clearance date is not credible without those inputs. Staffing also depends on client review capacity and payer response times.

Start with a defined case sample and track time to first action separately from final resolution. Cases waiting on clinical records or payer decisions remain visible. A pilot start date is not a backlog completion date.

Actigy BPO usually prices denial support per FTE by role after the process audit. Case complexity, coverage and required review affect the written quote. The scope must name tasks included in the queue.

Compare fees using the same work mix and retained costs. Clinical review, software and client approvals do not disappear when cases move. Define recovered cash carefully before comparing any alternative fee tied to recovery.

Hard and soft are informal labels for cases viewed as final or open to correction. Payers and billing teams do not use them uniformly. Neither label replaces the actual reason, appeal rights or filing deadline.

Actigy BPO checks the payer response and evidence before choosing an action. A case described as hard still needs policy review; a soft label does not establish that payment will follow.

An appeal packet needs the denial reason, relevant payer policy, claim details and evidence supporting the requested change. Depending on the dispute, that includes authorization proof, approved clinical records or a coding rationale.

Actigy BPO assembles the permitted material and records submission proof. The client approves clinical statements and disputed policy positions. Check the payer's required format and deadline; unnecessary patient data does not strengthen an appeal.