How to Reduce Claim Denials by 40% in 90 Days

The $262 Billion Problem

Every year, U.S. healthcare providers write off billions in revenue due to denied claims. The frustrating part? Studies show that 90% of claim denials are preventable.

Most denials fall into five categories: 1. Missing or invalid prior authorization — 26% of denials 2. Eligibility not verified before service — 22% of denials 3. Incorrect or incomplete patient information — 18% of denials 4. Coding errors (wrong CPT/ICD-10) — 17% of denials 5. Timely filing deadline missed — 11% of denials

The 90-Day Fix

Month 1: Plug the Eligibility Leak

The fastest ROI in RCM is real-time eligibility verification. Before we built GetMax, our clients were verifying insurance by phone — a 15-minute call that gave results valid for hours, not the moment of service.

What we changed: Every patient gets an automated eligibility check 48 hours before their appointment and again at check-in. The system flags any change in coverage status and alerts the front desk.

Result for our pilot practice: Eligibility-related denials dropped from 22% to 4% in 30 days.

Month 2: Fix the Prior Auth Gap

The most expensive denials are prior auth failures — not just because of the denied claim, but because of the 45-minute appeals process per claim.

What we changed: GetMax tracks authorization unit usage in real-time. When a provider sees the 8th visit for a patient with 10 authorized units, the system surfaces a warning and triggers a renewal request automatically.

Result: Prior auth denials dropped 68% across client practices.

Month 3: Close the Coding Loop

The last 17% of denials are harder — coding errors require a clinical eye. What technology can do is catch mismatches before the claim leaves your system.

What we changed: Automated CPT/ICD-10 compatibility checks at the charge entry stage. The biller sees a warning if a diagnosis code doesn’t support the procedure billed.

Result: Coding-related denials dropped 55% with zero additional staff.

The Compound Effect

By Month 3, practices running this workflow saw:

40% overall reduction in denial rate

$18k–$45k per month in recovered revenue (depending on practice size)

12 hours/week saved by billing staff on manual follow-up

The key insight: most of these fixes aren’t about working harder. They’re about getting the right information at the right moment in the workflow.

GetMax is built around this principle — surface the right signal (expired coverage, missing auth, coding mismatch) before it becomes a denied claim.