A large share of appealed denials are overturned. That means practices appealing least are not the ones with the cleanest claims — they are the ones leaving the most money behind, because the denials they accept include ones that would have been reversed.
There is a number that does not appear in vendor pitches: a substantial proportion of appealed denials are overturned. Not a trivial fraction. Enough that not appealing is a decision with a price.
What that implies
If appeals frequently succeed, then a meaningful share of denials were wrong when issued. Which means a practice that rarely appeals is not enjoying cleaner claims — it is absorbing incorrect denials as though they were correct.
The quiet part is that this is predictable from the payer's side too. Denials that go unappealed are cheaper than denials that get contested, and a low appeal rate is visible.
Why practices under-appeal
- Effort per claim. Appeals take real time, and small balances feel not worth it individually. Collectively they are the majority of the loss.
- No process. Without a defined path, each appeal is invented from scratch, which makes every one expensive.
- Stopping at the first level. The first level frequently has the lowest overturn rate. Practices that abandon there abandon at the worst possible point.
- Missed deadlines. The appeal was intended and the window closed while it sat in a queue.
The honest caveat
Not every denial is worth appealing. Some are correct, and some are past the window and unrecoverable regardless. The point is not to appeal everything — it is that the current threshold in most practices is set by available time rather than by recoverability, and those are very different filters.
Outcomes are decided by the payer, and no appeal rate changes that. But a denial nobody contested was decided by default.
Appeal capacity is a staffing decision
Appeals lose to new claims because new claims have a deadline everyone feels and appeals have one nobody watches. The fix is protected time rather than exhortation — a defined share of a person’s week that is not available for submission work.
Practices that leave appeals to spare capacity have decided not to appeal, whether or not they meant to.
Decide by category, not case by case
Deciding whether to appeal each denial individually is slow and inconsistent. Deciding once that medical necessity denials above a threshold are always appealed, and eligibility denials for genuinely absent coverage never are, turns a judgment call into a rule.
The rule can be wrong and corrected. The case-by-case approach cannot be reviewed at all.
The honest caveat
A high overturn rate partly reflects that practices appeal the denials they think they can win. Reading it as "most denials are wrong" overstates it.
What it supports is narrower and still valuable: there is recoverable money in the denials you are currently accepting without review.
Common questions
- What percentage of denied claims are overturned on appeal?
- A substantial share across the industry, which is why low appeal volume usually signals under-appealing rather than clean claims.
- Why do practices not appeal denials?
- Time, mostly. Appeals compete with new claims for the same staff, and the payoff is delayed while the next day’s submissions are immediate.
- Are all denials worth appealing?
- No. Some are correct, some are unrecoverable, and small balances can cost more to appeal than they return. The point is to decide rather than to default to accepting.
- How do I know if I am under-appealing?
- Compare denials received to appeals filed. If the ratio is very low and your denial mix includes medical necessity or bundling, you are leaving money behind.
- What should I track about appeals?
- Denial reason, argument used, and outcome. Within months that tells you which categories are worth appealing and which reliably fail.
Denials Piling Up?
We handle the revenue cycle end to end — coding by certified coders, claim submission, denial management and appeals, and A/R follow-up, with six reported numbers every month.