Medical Claim Denial Management: Practical Lessons from Taya Gordon for Medical Practices

Medical Claim Denial Management: Practical Lessons from Taya Gordon for Medical Practices

When Payer Decisions Move Faster Than Appeals

Most practices are not losing the denial fight because staff are careless. They are losing it because the two sides are not moving at the same speed. Payers now use AI-assisted review systems to process and deny claims quickly, while the appeal side of the equation, in most practices, is still largely a manual process of pulling records, writing letters, and tracking deadlines by hand. That speed gap is at the center of effective medical claim denial management, and it is a bigger driver of accumulating denials than most practices realize.

Shawntea "Taya" Gordon, MBA, FACMPE, CEO of Atlas & Perpetua Healthcare Consulting, spoke about this gap in an October 8, 2026 interview with Physicians Practice, conducted at the 2026 MGMA Annual Conference. Her central point is straightforward: payers can review and deny a claim quickly, while the practice side still depends heavily on manual effort to catch, prioritize, and appeal that same claim. Every reference to her views in this article comes from that interview.

Denial management, done well, is not about resubmitting claims faster. It is about fixing the processes that produce denials in the first place, so fewer claims need to be appealed at all. Gordon's broader observation, drawn from working with practices across the country, is that many billing teams have settled into a reactive pattern. Staff work whatever denial is loudest or most recent, rather than following a structured process, and that reactive habit is what allows the speed gap between payers and practices to turn into a real financial problem rather than a minor annoyance.

This article uses Gordon's observations as a starting point to walk through what a more deliberate approach looks like in practice: how to review accounts receivable in a way that actually surfaces problems, how to prioritize a growing appeals queue, how to catch payer downcoding before it quietly erodes revenue, and how to build a denial management workflow that holds up over time rather than falling apart the moment staff get busy. None of this requires new software or a large new hire. It requires a different way of looking at data the practice likely already has.

Why Denied Claims Keep Accumulating

Denials pile up in accounts receivable for a handful of recurring reasons, and most of them have more to do with process than with any single person's effort.

Manual appeal queues are one culprit. When appeals depend on a staff member remembering to check a spreadsheet or a shared folder, claims slip through, especially during a busy week or when someone is out sick. Unclear ownership compounds the problem. If it is not obvious whose job it is to work a specific denial, from identifying the reason to gathering documentation to submitting the appeal, the claim tends to sit until someone notices it is overdue.

Missed follow-up dates are another common cause. Every payer has its own appeal filing limit, and those limits vary by payer and sometimes by claim type. Without a system that flags these deadlines automatically, a practice can lose its right to appeal a claim simply because nobody tracked the clock. Inconsistent payer-specific processes add a further layer of friction, since what works for one payer's appeal portal or documentation requirements often does not transfer cleanly to another.

Not every denial calls for the same response, and this is where many practices lose time. Some denials are genuinely preventable and point to a front-end or coding issue that needs to be fixed at the source. Others need additional documentation or a straightforward correction and resubmission. And some require a formal, structured appeal because the payer is disputing medical necessity, a contract term, or a coverage decision. Treating every denial the same way, by resubmitting first and investigating later, wastes staff time and often misses the real reason the claim was denied in the first place. The more useful habit is to investigate the denial reason before deciding how to respond, since that determination shapes everything that follows.

A practical way to build this habit is to sort incoming denials into three buckets as soon as they arrive, rather than letting them land in one undifferentiated pile. The first bucket covers denials caused by something the practice controls directly, such as a missing modifier or an eligibility check that was skipped. These should route straight back to whichever front-end or coding step caused the problem, with a note on what to fix going forward. The second bucket covers denials that simply need more documentation or a corrected resubmission, which is often the fastest category to clear once someone is assigned to it. The third bucket covers denials that genuinely require a formal appeal, because the payer disagrees with a clinical or contractual decision rather than pointing to a practice error. Sorting denials this way at intake, instead of after they have already aged for several weeks, keeps the appeals queue focused on the claims that actually need that level of effort.

Stop Relying Only on 30-Day A/R Buckets

Many practices still review accounts receivable in the traditional 30, 60, 90, and 120-day buckets, treating that cadence as the baseline for how often a claim needs attention. Gordon's observation is that this interval no longer matches how payers actually operate. Because claims processing is now largely electronic, most payers respond within roughly 14 days, which means a 30-day review cycle leaves a claim sitting unattended for longer than it needs to before anyone looks at it again.

A broad 30-day bucket also hides where the real problem sits. Looking at aging in the aggregate, across every payer at once, can make a practice's overall A/R look reasonably healthy even when one specific payer is consistently slow or consistently difficult to collect from. Reviewing A/R by individual payer, rather than as one combined pool, is what actually surfaces which relationships need attention and which ones are working fine.

Gordon pointed to a specific signal worth watching closely: the share of a payer's balance that has aged past 120 days. When a meaningful portion of what one payer owes a practice has been sitting unpaid for that long, it is a clear, immediate item for the work queue rather than something to revisit at the next monthly meeting.

Charge lag deserves its own attention here too, since it is easy to overlook as a separate factor from collection speed. If a provider's documentation is not finalized and the charge is not entered until several days after the visit, that delay pushes the entire claim timeline back before the payer ever sees it. A practice that only measures how fast it collects once a claim is submitted can miss the fact that the real bottleneck sits earlier, in how long it takes to get the claim out the door in the first place. Separating charge lag from the rest of the billing cycle, and timing each step individually, often reveals where the actual delay is happening.

Beyond aging intervals, a handful of benchmarks matter more than most practices track consistently:

1. Net collection ratio. How much of the money a practice is actually entitled to collect, after contractual adjustments, it is actually collecting.
2. Days in accounts receivable. How long it takes, on average, to collect on a claim from the date of service.
3. Charge lag. The time between when a service is performed and when the charge is actually entered and billed, which affects every downstream step.
4. Percentage of A/R older than 120 days, broken out by payer. Not just the overall number, but which specific payers are driving it.
5. Denial rate and appeal outcomes. How often claims are denied in the first place, and how often appeals actually succeed once filed.

These benchmarks only create value if they drive specific action. A number that sits in a monthly report and gets acknowledged, then forgotten, does not change anything. The more useful approach is to let each benchmark generate a specific work queue, so that a rising percentage of A/R over 120 days for one payer, for example, becomes an assignment for someone on the team that week, not just a data point in a slide deck.

How to Prioritize Denied Claims and Appeals

Once a practice is tracking denials consistently, the next challenge is deciding what to work first. A denial queue that treats every claim as equally urgent tends to produce the same result as no queue at all, since staff end up working whatever is easiest or most recent rather than what matters most.

A practical prioritization approach organizes the queue around four factors. Appeal deadline comes first, since a claim that is about to pass its filing limit needs to move ahead of one with weeks of runway left, regardless of its dollar value. Claim value matters next, because a large-dollar denial deserves attention sooner than a handful of small ones, assuming deadlines are not already pressing. The denial reason itself should inform sequencing too, since some reasons are quick to resolve with a corrected resubmission while others require building a full appeal packet with supporting documentation. Finally, the amount of information still needed affects how quickly a claim can realistically move, so a denial waiting on a provider's note or a referral record may need to be flagged separately from one that is ready to submit today.

Every denied claim in the queue should have a clear owner and a defined next action, not just a status. "Pending" is not useful on its own. "Pending documentation request from Dr. Smith, due by Friday" is. Tracking submission dates, payer responses, supporting documents, and current appeal status in one place, rather than scattered across emails and sticky notes, is what allows a practice to actually measure whether its appeals process is improving over time.

It also helps to separate corrected claim resubmissions from formal appeals early in the process, since they are different workflows with different documentation requirements and different timelines. A corrected claim, where the original submission had an error that can be fixed and resent, moves faster than a formal appeal, where the practice is making a documented case that the payer's original decision was wrong. Mixing the two into a single undifferentiated queue tends to slow both down.

Identify Downcoding Before It Becomes a Revenue Leak

Downcoding happens when a payer reimburses a claim at a lower-level code than what the practice actually billed, without necessarily denying the claim outright. Because the claim still shows as paid, downcoding is one of the easier revenue leaks to miss. A claim that technically clears the system can still be quietly underpaid.

Gordon described a specific, practical way to check for this: pull every CPT code billed over the past six months, then compare those codes against what was actually paid on those same claim IDs. A pattern of differences between what was billed and what was paid is a strong signal of downcoding. Some payers disclose when they have downcoded a claim, noting it clearly on the remittance advice. Others do not make it obvious, which is exactly why a claim that shows as paid can still represent lost revenue if nobody is comparing billed codes against paid codes directly.

Once a discrepancy turns up, the next step is to check it against three things: the remittance advice itself, to see whether the payer documented a reason for the change; the practice's contract terms with that payer, to confirm whether the paid code is consistent with what was negotiated; and the clinical documentation, to confirm the originally billed code was actually supported. Tracking these discrepancies over time, by payer and by service type, turns a one-time check into an ongoing pattern that a practice can act on and, where appropriate, raise directly with the payer.

This check works best as a recurring habit rather than a single project. Running it every six months, as Gordon describes it, keeps the comparison current without turning into a full-time task, and it gives a practice enough data over a year or two to see whether a particular payer's downcoding pattern is a one-time anomaly or a consistent practice. A payer that downcodes the same CPT code repeatedly across many claims is behaving very differently from one with an occasional, explainable adjustment, and that distinction matters when deciding whether to raise the issue formally or simply keep monitoring it.

This kind of check carries more weight than it might seem. MGMA's 2026 Regulatory Burden Report found that claim denials and automatic downcoding both rank among the top five regulatory burdens practices report facing, with both tied specifically to Medicare Advantage plans. That context helps explain why a systematic downcoding check, rather than an occasional spot-check, has become a meaningful part of denial management rather than an optional extra.

Prevent Denials Before Claims Leave the Practice

The most effective denial management strategy is the one that keeps a claim from being denied in the first place. A few front-end checks catch a large share of preventable denials before a claim ever reaches the payer.

Eligibility and coordination of benefits verification confirms the patient's coverage is active and that the correct payer is billed first when more than one plan is involved. Authorization and referral checks confirm that any service requiring prior approval actually has it on file before the visit. Diagnosis and procedure coding accuracy, along with correct modifier use, keeps the claim aligned with what was actually documented and performed. And documentation accuracy ties all of it together, since a claim is only as strong as the clinical note that supports it. Each of these checks takes only a few minutes per claim, but skipping even one of them is enough to trigger a denial that then costs far more staff time to resolve after the fact than it would have taken to prevent.

These front-end steps deserve more depth than fits naturally in this article. Edge RCM has a dedicated guide covering common Medicare claim denials and how to prevent them, which walks through these prevention steps in more detail for practices that want to go further.

What Practice Leaders Can Learn from Taya Gordon's Revenue Leakage Discussion

Denial management does not exist in isolation. It is one piece of a broader revenue leakage picture, and Gordon has spoken about that larger picture as well, in a separate Physicians Practice conversation, Where the Money Leaks Out, with Taya Gordon. That discussion covers additional leak points practices commonly overlook, including uncollected patient responsibility at the front desk, undocumented services, aging vendor contracts that no longer reflect actual usage, and staffing decisions made without checking real workload data first. It is offered here as further context for practice leaders who want a wider view of where revenue tends to disappear, not as direct support for any specific claim made elsewhere in this article.

Build a Repeatable Denial Management Workflow

A denial management process that depends on one person's memory or a single busy week of catch-up work is not a process. It is a habit waiting to break. Building something repeatable means assigning clear daily and weekly review responsibilities, so that denials are triaged on a predictable schedule rather than whenever someone finds time.

Grouping denials by reason and by payer makes patterns visible that would otherwise stay hidden in a long, undifferentiated list. If a particular denial reason keeps showing up for a specific payer, that is a signal worth escalating to a process fix rather than resolving one claim at a time indefinitely. Escalation rules matter here too, with clear thresholds for when a claim needs to move up the chain, whether because a deadline is close or because the dollar value is high enough to warrant a manager's direct attention.

A workable cadence usually separates daily tasks from weekly ones. Daily work tends to focus on triage, sorting new denials into the categories described earlier and flagging anything with a near-term deadline so it does not get buried under newer items. Weekly work is where the bigger picture comes into focus, reviewing the full denial queue by payer and by reason, checking progress on claims already in appeal, and confirming that nothing has quietly missed its filing window. A practice that only does the weekly review, without a daily triage step, tends to let urgent claims sit until the weekly meeting catches them, which can be too late for a payer with a short appeal filing limit.

Regular review of appeal success rates and denial patterns, not just denial volume, shows whether the process is actually working or just staying busy. And because denial management touches more than billing, shared responsibility across billing, clinical, and administrative staff tends to produce better results than treating it as a billing-department-only problem. A documentation gap that causes a denial often starts in the clinical workflow, and a front-desk eligibility miss starts well before a claim is ever coded.

Conclusion: Turn Denial Data into Action

Effective medical claim denial management comes down to organized monitoring and timely follow-up, not heroic effort during a busy week. Reviewing accounts receivable by payer rather than in broad 30-day buckets, prioritizing appeals by deadline and value rather than convenience, and running a regular billed-versus-paid check to catch downcoding are three concrete habits that address where denials actually accumulate. Preventing repeat denials by fixing the front-end issues that cause them in the first place closes the loop, so the same problem does not keep resurfacing month after month.

The most practical takeaway from Gordon's perspective is also the simplest one: use your own claim data to find your biggest revenue leak first, rather than guessing at what might be wrong or copying another practice's priorities. The answer is usually already sitting in the practice's own A/R and remittance data. It just needs someone looking at it consistently, with the right questions in mind.

Edge RCM CTA

If reviewing A/R by payer, prioritizing appeals, or running a billed-versus-paid downcoding check sounds like more than your team has bandwidth for, Edge RCM manages denial follow-up and A/R monitoring for practices as part of its revenue cycle services. Reach out to see how a dedicated denial management process could work for your practice.