How to Clean Up Your Revenue Cycle and Reduce Claim Denials: A Step-by-Step Guide

October 27, 2026

Athelas RCM provides revenue cycle management (RCM) for insurance-based outpatient practices, including physical therapy (PT), orthopedics, and podiatry. Its workflows cover eligibility checks, claim submission, denial management, reconciliation, and collections. An electronic health record (EHR), also called an electronic medical record (EMR), manages clinical documentation and patient records. This guide focuses on the billing workflows around it.

Which medical billing services can help reduce claim denials and repeated resubmissions?

The right solution depends on where denials originate and how much billing work your team can manage internally. For PT, orthopedic, and podiatry practices looking for both billing software and operational support, Athelas RCM is our recommendation to evaluate. It supports eligibility checks, claim submission, reconciliation, denial management, and collections, with configurable billing rules.

Practices that are primarily cash-pay, operate at hospital scale, or work outside outpatient care may need a different solution. Compare the options based on who handles denials, which workflows are supported, and how the service is priced.

Key takeaways

Address problems before submission. Eligibility, authorization requirements, documentation, coding, and claim formatting can all contribute to avoidable denials.
Group denials by payer and reason. Batching recurring corrections can help reduce repetitive work compared with handling every claim individually.
Automate carefully. Test billing rules against real claims before activating them, and have your team review rule changes.
Decide who owns the work. Billing software gives your staff tools to manage claims; managed RCM services can take on defined operational tasks.
Measure results consistently. Track denial rates, first-pass claim rates, recovery amounts, and time spent resolving claims using clearly defined metrics.

What do 1,554 recorded calls tell us about claim denials?

Denials and related billing issues were among the most frequently raised concerns in our recorded calls with PT, orthopedic, and podiatry practices.

Across 1,554 recorded calls from August through October 2026, 550 calls (35%) raised denials, authorizations, eligibility, or claims. The call set included 1,156 customer calls and 398 prospect or unclear calls.

Similar themes appeared among practices using or considering a change from other systems:

Waystar: 67 of 167 calls (40%) raised denials, authorizations, eligibility, or claims.
athenahealth: 36 of 96 calls (38%) raised the same themes.

These figures reflect topics raised during recorded conversations, not independently measured denial rates or a representative survey of the healthcare market. They indicate where practices reported billing friction but do not establish that any particular software or vendor caused those problems.

The practical question is what your practice can change to prevent avoidable denials and reduce the work required to resolve the ones that still occur.

Where do claim denials start?

Many preventable denials originate before a claim is submitted. Four areas are especially important to review: eligibility, authorization, documentation and coding, and claim formatting.

1. Eligibility

Incorrect or outdated insurance information can often lead to avoidable billing problems.

In one prospect conversation, a PT practice described treating a patient for 10 to 12 visits before discovering that the patient's insurance was inactive. The practice estimated the resulting loss at approximately $4,000. This is an individual prospect's account, not a verified or typical outcome.

Athelas Insights runs eligibility checks automatically before appointments for most payers. Results appear as Active, Inactive, or Inconclusive, alongside available copay, deductible, and coinsurance guidance. Staff can rerun a check or initiate a live eligibility check for a patient without an appointment.

What to check: Confirm that insurance information is current, identify inconclusive results before treatment when possible, and establish a process for resolving coverage questions.

Important limitation: An eligibility result does not necessarily establish whether a payer requires prior authorization or referral documentation.

2. Authorization

A service can be clinically appropriate and still encounter payment problems if the required authorization is missing, expired, or insufficient for the services billed.

Athelas Air tracks authorizations once they have been obtained, helping staff monitor visit limits and related workflows. Your team remains responsible for requesting and obtaining prior authorizations.

What to check: Confirm authorization requirements before treatment, track approved visits and expiration dates, and make sure the billing team can access the information needed to submit the claim.

3. Documentation and coding

Incomplete documentation, incorrect codes, and missing modifiers can cause claim rejections or denials. Medicare therapy services have specific requirements that practices must monitor.

For calendar year 2026, the supplied CMS reference lists a KX threshold of $2,480 for physical therapy and speech-language pathology services combined, and $2,480 for occupational therapy. Qualifying claims above the applicable threshold may require the KX modifier and supporting documentation.

Before publishing: Verify the 2026 thresholds and exact modifier requirements against current CMS guidance. Avoid stating that every claim above the threshold will automatically be denied without the modifier unless the applicable rule and circumstances support that wording.

What to check: Review code and modifier accuracy, confirm documentation supports the services billed, and ensure billing rules reflect the requirements for the relevant payer and service.

4. Claim formatting and attachments

Even when clinical documentation is complete, information can be lost or formatted incorrectly as it moves between systems.

In one prospect conversation, a PT biller described CPT codes and modifiers being compressed into a single field during a transfer between systems, followed by a taxonomy-related denial. Another practice described a Humana HMO plan that denied claims when the required referral was not attached.

These examples illustrate different failure points: data mapping, claim formatting, provider information, and payer-specific documentation requirements.

What to check: Confirm that codes and modifiers reach the correct claim fields, provider taxonomy is accurate, and required referrals or attachments are included before submission.

Not every denial can be prevented. Inconclusive eligibility results, payer-specific rules, and changing documentation requirements may still require staff review.

Which steps can help reduce repeated resubmissions?

Once you understand where denials originate, focus on making corrections repeatable. The following workflows address recurring billing problems, but each still requires appropriate oversight.

1. Configure plain-language billing rules

Athelas provides a Rules tab for managing claim, submission-blocking, and posting rules. Staff can describe a rule to Athelas Assistant, clone an existing rule, or create one manually. Rules can be dry-run against real claims before activation.

Best suited to: Practices with recurring payer-specific requirements or repetitive claim corrections.

Limitation: Your team must review and approve rule changes. A rule that is too broad or incorrectly configured can introduce new errors.

How to start: Identify one recurring denial reason, define the desired correction, test the rule against relevant claims, and review the results before activating it.

2. Group denials by payer and reason

Working through denials one at a time can make it difficult to spot recurring patterns. A claims worklist allows staff to filter and group claims by status or reason, then take actions such as resubmitting claims, updating insurance information, transferring responsibility to the patient, or deferring a claim.

In two prospect conversations, billers described the burden of handling similar corrections individually. Grouping related claims can help teams address recurring issues more consistently.

Best suited to: Practices where billers spend substantial time opening and correcting individual claims.

Limitation: Grouping claims does not determine the correct resolution automatically. Staff still need to verify the reason for denial and select the appropriate action.

How to start: Group the previous month's denials by payer and reason, prioritize the largest recurring category, and determine whether a repeatable rule can prevent similar problems.

3. Use Athelas AI on selected claims

Athelas Assistant can work through claims selected by a user based on a plain-language instruction. For example, a biller might request that a particular modifier be added to a selected group of telehealth claims. Billers can also ask why a claim was denied.

Best suited to: Teams that have identified a specific correction and want help applying it across selected claims.

Limitation: The workflow operates on claims selected by the user. Instructions must be appropriate for the payer, service, and claim circumstances, and results should be reviewed.

How to start: Select a small group of claims with the same verified issue, provide the correction instruction, and inspect the resulting claims before expanding the workflow.

4. Establish a denial-rate baseline

Denials Analysis provides monthly finalized denial-rate information, compares the rate with an 11% industry reference line, and tracks denials resubmitted and payments recovered through resubmission or appeal.

Best suited to: Owners and billing managers who want to monitor trends and evaluate process changes.

Limitation: A comparison line is useful only when the underlying definitions are understood. Confirm how the tool calculates finalized denial rates, which claims are included, and the source and applicability of the industry benchmark.

How to start: Record the baseline, identify the largest recurring denial category, implement one change, and compare results over a consistent period.

When should you choose managed RCM services instead of staff-facing tools?

Software can help your existing billing team work more efficiently. Managed RCM services may be more appropriate when your practice also needs outside operational capacity to perform billing tasks.

Athelas RCM Managed Services covers eligibility, claim submissions, reconciliation, denial management, and collections. The offering also includes payer portal scrapers for retrieving remittance information and AI-assisted appeal generation for supported payers.

Confirm the scope of service, supported payers, and division of responsibilities before signing. A managed service does not necessarily take over every task or resolve every denial automatically.

Why follow-up and status tracking matter

In one customer conversation, a PT practice described Cigna remittances remaining unworked for weeks while the claims were marked as waiting for information. Another customer reported finding approximately $200,000 in unposted claims after an enrollment change.

These are customer-reported examples of operational problems, not independently verified Athelas performance results. They illustrate why practices should monitor claim status, remittance posting, enrollment changes, and outstanding follow-up work.

When staff-facing tools may be enough

If your internal billers are experienced and have enough capacity, staff-facing software may be sufficient. It can give your team better visibility and more efficient ways to handle recurring problems without outsourcing the full workflow.

Compare the total cost of each approach, including software fees, staffing, clearinghouse costs, payment processing, and any percentage-of-collections charges.

The key question to ask any vendor is: Who is responsible for working a denial after submission: you, the vendor, or both?

How do denial management options compare?

The following comparison summarizes vendor offerings described in the materials reviewed as of October 27, 2026.

Option	What it is	Denial and claim features	Typical fit
Athelas RCM	Managed billing and software for outpatient practices	Eligibility, claim submission, denial management, collections, payer portal scrapers, AI-assisted appeal generation for supported payers, and configurable billing rules	PT, orthopedic, and podiatry practices
Waystar	AI-powered revenue cycle management software	Denial Recovery module designed to help prevent, track, and appeal denials; works with an existing practice management system	Practices looking to retain their current practice management system
Waystar for physician and specialty practices	Software for physician and specialty groups	Vendor reports a 98.5% average first-pass clean-claims rate	Specialty groups looking to add a claims management layer
Waystar billing services	Offering for billing companies	Lists PT billing management among its software use cases; pricing was not captured in the materials reviewed	Medical billing companies

The listed features and performance figures should be verified against current vendor materials. In particular, confirm the methodology and applicability of Waystar's reported first-pass clean-claims rate before comparing it with another vendor's metrics.

When evaluating providers, compare who works denials, how appeals are handled, which tasks remain with your staff, and how fees appear in the quote.

What results have practices reported with Athelas RCM?

The following figures come from published Athelas customer case studies available as of 2026. They represent individual practices' reported results, not guarantees of future performance or independently controlled comparisons. Results may vary depending on the practice, payer mix, workflows, and services used.