You know exactly who she is. She knows which payers stall, which appeals need extra follow-up and, off the top of her head, why the same four denials keep landing in the queue.

She has never had time to do anything about it.

That's not a small problem. A Jan. 6, 2026, MGMA Stat poll found denials and appeals are the single largest source of revenue cycle leakage for medical groups — 48% of leaders named them first, ahead of front-end issues at 23%.¹ Assigning appeals and root-cause analysis to the same person sounds efficient. In practice the appeals queue wins every time, and the analysis never happens.

That trap came up again and again during the Aug. 6 webinar, Denial Trends Decoded: Turning Data Into Dollars (With Half the Staff), featuring James Muir, senior vice president of physician services at UnisLink. Muir called it a treadmill: staff fully intend to get to prevention, but they never get caught up enough to start.

Run the numbers before you argue about staffing

Muir walked through a real primary care group — 57,600 annual encounters, $131 average revenue per encounter, and a 14% initial denial rate.

That produces 8,064 denied encounters worth just over $1 million. Working them costs roughly $353,000 in labor at $43.84 per denial. At a 54% recovery rate, the group gets back about $570,000. Net gain: roughly $217,000.

Think on that: A better-than-average practice chases $1 million and keeps about a fifth of it — and that's the optimistic version, where the team actually reaches every claim. Muir's assessment work suggests most groups don't come close.

If anything, $44 per denial is a floor. Premier's most recent survey of hospitals and health systems put the average administrative cost of fighting a denial at $57.23 per claim, up from $43.84 the year before.²

That number is your business case. Divide $353,000 by a biller's salary and you have a rough FTE equivalent that your denials are quietly consuming — the figure to walk into your next leadership meeting with.

Know your two denial rates, not one

Initial denial rate is denied claims divided by claims submitted. Final denial rate uses only what's still denied after appeals are exhausted. Benchmarks Muir cited: 16%–20% initial, 2%–5% final, with under 2% achievable.

Two cautions: Most practice management (PM) systems report denials badly, so pull the data into a pivot table and group by encounter number — otherwise a claim denied three times counts three times and inflates your rate. And once you have the percentage, run a dollar-based version. Percentages benchmark; dollars get budget approved.

Read denials as an operations report

Every denial is feedback about a process, which is both the good news and the bad news. Break the data down four ways: service location, payer and financial class, CPT® and service grouping, then denial code and category.

Muir's example: Medicaid denials running above 27%, driven by CO-197 (missing authorization), concentrated in CPT 17110 skin lesion removals, worst at one location. That isn't a generic denial-rate problem. It’s a specific pre-auth workflow to investigate. And if another location barely has the same problem, find out what that team is doing differently and whether it can be standardized.

Three KPIs that tell you if you're staffed for the work

1. Revenue realization rate — payments plus all adjustments divided by charges, run 90-plus days back. Benchmark is 99%–100%. Anything lower can signal unfinished work.
2. Insurance A/R over 120 days — split from patient A/R. When most aged A/R still sits with payers, it is a strong sign the team is falling behind on payer work. Because patient balances usually get collected after insurance adjudicates, that backlog hits patient collections, too.
3. A/R days — benchmark 30. Muir ranks it third deliberately: it can be gamed. Under pressure, staff write off faster than they appeal.

Prevention is cheaper than recovery

Muir puts roughly 90% of denials in the preventable column. Eligibility, authorization, demographics, coordination of benefits, timely filing — all upstream of the payer.

Front-end denials are also where the volume is; UnisLink's assessment work finds 50% to 60% of a practice's denials originate there, and about 55% of eligibility denials are never recovered once incurred. Prevent them and you never pay the $44.

The most actionable fix Muir offered: confirming active coverage is not the same as verifying that the specific service is a covered benefit. Many systems check the first automatically and skip the second. Ask whether yours returns a full 271 benefits file — and plan for a human to read it, because portal checks and payer calls still fill the gaps.

Everything else is a spectrum, not a mandate. Collecting copays at check-in is good; estimating patient responsibility from a cheat sheet is better; electronic estimation against the contract is best. Pick the version you can actually staff, prevent the denial you're getting today, then move up. Pair it with a standing cadence — review denial reports monthly at minimum, with the team reviewing patterns together.

The one investment Muir insists on: someone whose job is preventing denials, not working them. That role costs money, but Muir’s point is that prevention needs an owner; otherwise, the appeals queue will keep consuming time meant for root-cause work and groups remain stuck on the treadmill.

Notes

1. Harrop C. "Detecting and fixing leaks across the revenue cycle." MGMA. Jan. 7, 2026. https://www.mgma.com/mgma-stat/detecting-and-fixing-leaks-across-the-revenue-cycle
2. "Claims Adjudication Costs Providers $25.7 Billion." Premier Inc., Feb. 24, 2025. https://premierinc.com/newsroom/policy/claims-adjudication-costs-providers-257-billion-18-billion-is-potentially-unnecessary-expense