Claims Appeals: How to unburden staff and improve denial overturns

When denial rates were under 10%, provider organizations could ignore them, leading to the often-cited statistic of 50 to 65% of denials never getting appealed. 

But with KFF’s independent analysis of federal Affordable Care Act transparency files showing Marketplace insurers denied 19% of in-network claims this year, provider organizations must light a fire under their claims appeals to stem revenue leakage and remain viable. 

Today, denials are getting more complex and coming in at a faster rate than the RCM workforce can manage. More are turning to revenue cycle management automation to get their claims appeals to payers. 

With revenue cycle automation, claims appeals aren’t as onerous as they once seemed. RCM automation reduces the workflow burden and improves success rates, making the initial work more worthwhile for all involved. 

First, generative-AI tools now draft denial-specific appeal letters in seconds, replacing what once took hours of staff time. It can respond to denials faster and smarter. The lynchpin in keeping denial rates under control is the provider appeal letter. Given that 54% of private payer denials are overturned, provider organizations stand to gain meaningful revenue if they take a proactive approach to modernizing their claims appeals processes. 

What are claims appeals? 

A claims appeal is a formal request asking a health insurer to review and overturn an adverse benefit determination—such as a refusal to pay, reduce, or authorize a medical claim. Patients or their providers first file an internal appeal with the insurer. If the denial stands, they may pursue an external review by an independent third party, ensuring the payer no longer has the final say. 

Every denied dollar is lost revenue until it is successfully contested. Systematic appeals processes—especially those now supported by automation—let healthcare organizations recapture that revenue, shorten accounts receivable cycles, and protect already-thin operating margins. 

4 ways claims appeals are evolving  

1. AI platforms draft appeal letters

AI-powered platforms now draft payer-specific appeal letters in seconds, shrinking staff effort from hours to mere minutes and cutting turnaround times from weeks to days. These platforms include: 

• Waystar Altitude Create™ - Uses generative AI and a 1,000-plus library of payer forms to assemble denial-specific letters, attach evidence, and file packages electronically. 
• Aspirion AI Appeal Manager - Extracts denial codes and clinical data, inserts policy citations, and writes comprehensive appeals that mirror attorney-level arguments.
• Cofactor AI Denials Suite - Pulls EHR notes, past appeal outcomes, and legal requirements to produce case-specific letters for audits and retroactive denials.

Providers are eager to invest in AI that reduces administrative waste, enhances operational efficiency, and improves interactions with payers and patients.

2. Contract management software is illuminating denials

Provider organizations face significant barriers to getting eyes on their denials. Contract management software captures every denial, underpayment, and reversal —and then displays those items in a sortable, drill-down table. An all-inclusive, easy-to-navigate denial table turns raw payment data into an actionable to-do list, helping provider organizations conduct claims appeals.  

With concrete revenue insights, providers can conduct:

• Rapid triage: Staff can instantly filter by dollar value, payer, or denial code to zero-in on the highest-impact items instead of combing through disparate reports.
• Accountability: A shared, real-time list shows which claims are assigned, in progress, or resolved, reducing duplicate effort and “lost” appeals.
• Root-cause insight: Side-by-side columns for denial reason, CPT/ICD code, and registration data reveal patterns (e.g., eligibility errors with a specific front-desk location) the moment they emerge, so teams can fix workflows before denials pile up.
  
  
• Faster cash recovery: Batch actions—such as auto-generating appeal letters or bulk resubmitting corrected claims—can be launched directly from the table view, shrinking days in A/R and improving cash flow.
  Stronger negotiating leverage: Aggregated, line-level evidence of payer behavior (recurring underpayments, systemic down-codes) arms finance leaders with hard data for contract talks and escalation packages.
  
  

 Take a quick, self-guided tour through a powerful RCM tool that optimizes contract performance, denial management, and payer reimbursements. 

Eyes on contract rates and terms pays off. 

An orthopedic management services organization overseeing more than 200 surgeons discovered that its legacy vendor, Experian, was missing payer underpayments, leaving cash on the table just as the group prepared for rapid growth. 

The MSO adopted MD Clarity’s RevFind to digitize all payer contracts and auto-compare every incoming payment against agreed rates. Initial hurdles included cleaning complex, multi-procedure claims data and integrating the new platform with the practice-management system, but MD Clarity’s onboarding team uploaded contracts, configured routing rules, and trained staff within weeks. The results were decisive: the tools surfaced $10.3 million in underpayments (13% of revenue), and spared the MSO a planned $43,000 staffing add. 

Contract management software strengthens claims appeals

Contract-management platforms do far more than store fee schedules. By digitizing every clause and rate, the software gives revenue-cycle teams the factual ammunition and real-time insights they need to assemble claims appeals

1. Instant access to the “smoking gun”

• All payer agreements live in a searchable repository, so staff can pull the exact paragraph that guarantees a CPT rate or a timely-payment clause and drop it—verbatim—into an appeal letter in seconds. 
• Centralization eliminates the hunt through email threads or outdated binders and prevents missed filing deadlines.

2. Automated Underpayment & Denial Detection

• The system compares each Electronic Remittance Advice against contracted rates as payments post, flagging discrepancies before they age out of the appeal window. 
• Those variances show up in worklists with payer, location, and dollar value, letting staff target the highest-impact cases first.
  

3. Data-Driven Proof for Appeals

• Tables and drill-down charts quantify how often a payer violates its own contract—powerful evidence that moves appeals from “request” to “breach-of-contract” demand in an appeal.
• Historical win-rate analytics guide which denials are worth the effort, boosting ROI on limited staff time.
  

4. Faster Letter Generation & Submission

• Advanced contract tools integrate with denial-management or RPA systems. Once a variance is confirmed, the platform can auto-populate payer-specific templates with contract citations and dollar amounts, then route the packet for e-submission. The result is that appeals go out days faster, shrinking A/R and avoiding write-offs.

Contract-management software turns static PDFs into a living knowledge base that powers reactive appeals. By pairing automated variance detection with clause-level visibility, providers convert incorrectly denied claims into airtight, contract-backed appeals—recovering revenue faster while cutting staff workload.

3. Predictive scoring focuses effort where it pays

Machine-learning-based claims appeals platforms model rate each denial’s likelihood of overturn and surface only high-value claims for staff review, preventing teams from drowning in low-probability work. Waystar and Aspirion both use machine learning to prioritize high-value claims. Their solutions do more than report reimbursements and denials. The model learns which arguments succeed with each payer and writes the letter automatically. 

These solutions are already making gains for providers

A Pennsylvania nonprofit health system was struggling with a growing stack of denials that staff had to triage manually, a process prone to bias and missed revenue. 

The analytics firm they hired examined 2,473 denied admissions from 2020-2023. Based on those insights, they built six machine-learning models to predict which cases were most likely to be overturned on appeal. They settled on an elastic-net logistic-regression model that demonstrated 84% accuracy, 84% precision, and 98% recall. 

Key hurdles included imbalanced data, model calibration, and distinguishing lengthy stays due to medical complexity versus discharge barriers. Calibration techniques and targeted feature engineering resolved most issues. 

In the end, the automated triage tool cut manual screening time and focused staff on winnable cases. Most importantly, the health system’s monthly appeal volume doubled, and the number of overturned denials nearly doubled as well. By converting previously lost claims into payments, revenue improved. 

4. Digital first appeals submissions

Keep in mind that big payers such as UnitedHealthcare are moving to all-digital reconsideration and appeal workflows, a move that means providers in multiple states must submit appeals electronically after June 2, 2025. 

Conducting claims appeals in an environment of shifting payer rules 

No two insurers—sometimes no two denial types within the same insurer—follow the same playbook for claims appeals. Meeting each payer’s unique documentation, formatting, and filing-deadline rules demands rapid turnaround and painstaking record-keeping from already overextended clinical and revenue-cycle staff. When those details are overlooked, the appeals process drags on, consumes scarce labor, and invites mistakes. 

You can simplify claims appeals with these tactics: 

• Build a single, searchable “payer rulebook.” Maintain an online repository that lists every major payer’s appeal instructions, required attachments, time limits, and contact paths so staff can find authoritative guidance in seconds.
  
  
• Create modular appeal templates. Develop core letter and packet formats for the most common denial categories, then drop in payer-specific language and patient details instead of starting from scratch each time.
  
  
• Use denial-management software with payer logic. Modern platforms store rule sets, pre-populate forms, flag missing items, and even suggest persuasive wording tailored to the denial code and insurer.
  
  
• Designate a clinical liaison. Establish a clear workflow—and a single point of contact—for pulling clinical notes or clarifications so administrative staff aren’t chasing busy physicians for information.
  
  
• Schedule ongoing policy sweeps and micro-trainings. Assign someone to monitor payer bulletins, refresh the rulebook, and deliver short, regular updates to the appeals team to prevent errors rooted in outdated guidance and to keep first-pass claim accuracy high.

With these tactics, you can transform a chaotic, error-prone process into a disciplined workflow. The result is faster, cleaner claims appeals that recapture revenue without exhausting already stretched clinical and billing teams.

Limited claims appeals staff? Denial recovery services gets it done

Claims appeals software surfaces your reimbursement data sliced and diced into a variety of critical insights. But if staff doesn’t have the time to get on the phone with payers or submit to their portal, your appeals opportunities disappear. Some denial management software companies offer expert denial recovery services to get this important work done. These specialists step in as an extension of the RCM team. They draft appeal packets, cite the precise contract paragraphs RevFind surfaced, and attach required clinical or coding documentation. Specialists submit appeals through payer portals, escalate by phone or email when necessary, and track status changes back in the software for full visibility.

A comprehensive system can provide the analytics to uncover the claims appeals opportunities that seasoned experts prosecute without overloading internal staff.

MD Clarity contract management software fuels claims appeals

Claims appeals are evolving from paper-intensive, manual tasks to streamlined, AI-powered, data-driven workflows. By embracing automation now, providers can absorb surging denial volumes, satisfy new e-submission requirements, speed up revenue recovery, and redeploy limited RCM staff to more strategic work.

Take charge of denials, appeals, contract variances, and underpayments with the RevFind contract management platform. The platform marries automated analytics with payer-reimbursement experts to deliver end-to-end revenue recovery. With this solution, you can drill into denial patterns by payer or CPT code, see the dollars at stake, and queue claims for bulk appeal using stage tags and account labels. While RevFind pinpoints and organizes the work, our specialists craft high-yield appeals that clear backlogs and lift net revenue—turning hidden variances into cash without overloading your RCM staff.

Find out how you can unleash a powerful, two-pronged approach to winning more claims appeals.  Schedule a demo today! 

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