Decode the denial. Fix the workflow that caused it.
Denials are the symptom of an upstream issue. Preventing denials means fixing the workflow that caused it. This is a working catalog for denial patterns. We help you trace each denial back to its cause, then give you strategies for appealing it, and preventing it in the future.
Medicare Advantage insurers fully or partially denied 4.1 million prior authorization requests in 2024. Only 11.5% of those denials were appealed, but 80.7% of the appeals that were filed came back partially or fully overturned.
Source: KFF analysis of CMS data, January 28, 2026 (2024 determinations).
Mindy Corbett, CSPO, CPC, CPB, CPPM, founder of ROI That Works: “A denial code is a category, not a verdict. The overturn rate tells you what happens to these decisions when somebody actually answers them.”
Denial Briefs. Patterns and Workflow Strategies.
A growing catalog of denials for all practice types. Continuously updated. We identify the pattern, the cause, and provide the fix. You validate the result.
CARC 16
Claim/service lacks information or has billing/coding errors. The most common denial across every specialty. Usually fixable at intake.
Read the Denial BriefCARC 119
Benefit maximum has been reached. A boundary problem masquerading as a billing problem. The fix is at eligibility, not appeal.
Read the Denial BriefCARC 4
The procedure code is inconsistent with the modifier used. Modifier discipline at coding is the only durable fix.
Read the Denial BriefCARC 49
Routine, preventive service. The CARC that catches up to a billing chart that did not document the encounter type correctly.
Read the Denial BriefCARC 97
Bundling. The benefit for this service is included in the payment for another service already adjudicated. National Correct Coding Initiative (NCCI) edits at the source.
Read the Denial BriefHow a denial brief is written.
Denials become the focus of a brief based on industry signals, and customer feedback. Denial briefs are built following the same format each time. First, we define the issue (pattern), then we identify the cause, and share the fix. The final step is validating your results.
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01
The Pattern
A plain language explanation of the denial. We do not expect you to decipher the technical jargon, or wonder what the payer means.
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02
The Cause
The issue that actually caused the denial such as missing or mismatched modifiers, registration errors, or missing authorizations.
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03
The Fix
The actual change required to correct the workflow. Not fluff. Real, actionable steps you can take to make lasting changes.
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04
The Result
The evidence that the fix worked. Improved denial rates. Improved Days in A/R rates. Improved first pass clean claim rates, and improved first pass denial rates.
Tell us which denials are causing you the most frustration.
If you have a denial that is impacting your A/R that we don't have in our catalog yet, we can write it. Send us an email at hello@roithatworks.com with the subject "denial pattern" and give us some information about what you are experiencing.