An Undeniably Credible Approach to Denials

By Ellen Catania, RN, Vice President of Review Operations 

Experian’s recent “State of Claims” report shows that 68% of providers said denials are occurring at a higher rate than a year ago, and 89% of providers said reducing denials is a priority for their organization in 2026, up from 82% in 2025.   

One way to help reduce the likelihood of denials is to understand the rationale for denials so they don’t keep happening.   

This is one potential risk for organizations that are over-reliant on artificial intelligence, since many AI models cannot clearly explain why a specific code or diagnosis was selected. If an auditor questions a claim, an unexplainable AI decision leaves the practice unable to defend its billing.   

In contrast, our in-house experts approach each denial with a learning mindset and have the deep expertise to respectfully debate with providers, offering thoroughly cited rationales for the decision. It’s this kind of objective review that keeps our appeal overturn rate among the lowest in the industry, while preserving the provider-payer relationship.  

Unpacking an unbundling claim   

Here’s one example. MedReview flagged a Medicare claim for denial on the basis that the services it reflected were improperly unbundled. In response, the provider – as any good provider would do – defended the claim. Our expert reviewer offered more than seven timely and professional rebuttals to the provider to explain the rationale behind the decision, including:    

• Clarifying that an outlier payment is an add-on to the DRG payment, not a charge-based or fee-for-service reimbursement. 

• Distinguishing state Medicaid guidance from the federal Medicare requirements that govern the claim.  

• Identifying that the provider’s calculation example was hypothetical, was not tied to any actual claim, and contained internal math inconsistencies.  

• Inviting the provider to submit a specific claim, line items and supporting documentation for a claim-specific re-review. 

• Detailing the claim-specific elements of the Medicare outlier methodology.  

• Explaining that the denied item was already captured in another billed and reimbursed charge, in keeping with Medicare billing principles.  

“Removing the duplicate charge corrects the claim; it does not make the [cost-to-charge ratio] calculation ‘inaccurate.’” 

– excerpt from medreview rebuttal

Healthy debate preserves the payer-provider relationship   

The result: our findings were upheld on appeal. The exchange stayed productive, and our reviewer’s clear, objective explanation gives the provider what it needs to avoid a similar denial in the future. 

The benefit doesn’t stop there. Our clients tell us their providers value the clarity and detail of our findings letters, and some have used them to train their teams on accurate billing and coding. 

There are several potential reasons for the rise in claims over the past few years. Some are beyond an organization’s control. But working with a partner who can clearly articulate the intricacies of a claim denial – and who is willing to go to the mat for you in the name of defensible audits – can help reverse this industry trend.   

Ready for audits you can defend with confidence? Contact us at hello@medreview.us to learn more.