Example Orthopaedic Group
last 90 days · 171 denials · $48,011 billed · 4 payers
Recoverable
$32,581
Of billed
68%
Denials
111
Rework by hand
~83 h
Winnable now
Appeal these. The money is usually recoverable.
Amount
$18,201
Denials
69
| Code and payer | Denials | Billed |
|---|---|---|
|
CO 197 Aetna
The payer says no prior authorisation was on file.
Request a retro-authorisation. Many payers allow one inside 30 to 90 days. If auth existed, appeal with the auth number and date. |
14 | $8,420 |
|
CO 151 UnitedHealthcare
The payer says the records do not support this many units or visits.
Appeal with the timed-code minutes and daily notes. Check the 8-minute rule maths first. |
31 | $5,591 |
|
CO 97 UnitedHealthcare
The payer says this is already paid inside another service.
If the services were genuinely separate, appeal with modifier 59 or an X modifier and the operative note. |
18 | $2,740 |
|
CO B7 Aetna
The provider was not certified or eligible for this service on that date.
Usually an enrolment or credentialing gap. Fix the enrolment and appeal for the back period. |
6 | $1,450 |
Fix and resubmit — not an appeal
Corrections. Appealing them burns the deadline instead.
Amount
$5,280
Denials
33
| Code and payer | Denials | Billed |
|---|---|---|
|
CO 16 Humana
Something the payer needed was missing or wrong on the claim.
Read the RARC beside it; that names the missing item. Correct and resubmit. |
22 | $3,300 |
|
OA 109 Cigna
Wrong payer or wrong contractor for this claim.
Identify the correct payer and rebill. |
11 | $1,980 |
Winnable, needs a clinician to attest
Winnable on the merits, but someone clinical has to sign.
Amount
$9,100
Denials
9
| Code and payer | Denials | Billed |
|---|---|---|
|
CO 50 Cigna
The payer decided the service was not medically necessary.
Appeal with the chart note and the payer policy or LCD it cites. A clinician must attest. |
9 | $9,100 |
Probably lost
Recoverable only with unusual evidence. Triage by value.
Amount
$3,430
Denials
20
| Code and payer | Denials | Billed |
|---|---|---|
|
PR 204 Humana
Not covered under the patient’s current benefit plan.
Check for an ABN or a patient waiver, then bill the patient or write off. |
13 | $2,310 |
|
CO 29 UnitedHealthcare
Filed after the payer deadline.
Only recoverable with proof of timely submission: a clearinghouse acceptance report, or evidence the primary paid late. |
7 | $1,120 |
Not a denial
Patient responsibility or a contracted write-down. Not money you lost.
Amount
$12,000
Denials
40
| Code and payer | Denials | Billed |
|---|---|---|
|
CO 45 Aetna
Charge is above the contracted rate. The difference is written off.
Contractual adjustment. Only worth review if the fee schedule loaded wrong. |
40 | $12,000 |
What happens next
Nothing is scheduled. This is yours to act on or ignore.
- Start with the Winnable now block. Biggest number here, and every line in it takes the same work.
- Check one row against your system. Confirm the count and the amount. If either is off, tell us.
- Reply and we take it from here. We work the Winnable now lines with you, or hand you the list and step back.
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