Turning a Denial Spike into a Prevention Strategy

Problem

A large orthopedics practice with 40+ providers and 115,000 patients per year experienced a major surge in denials for their largest payer across all Physical Therapy (PT) clinics. Without clear visibility into what was driving the spike, the practice risked ongoing financial loss and delayed reimbursements.

Solution

Adonis Intelligence surfaced an alert that flagged a 104% increase in denials linked to CARC code CO197 (“Precertification/authorization/notification absent”). By highlighting this unusual trend, the platform provided the client with a clear starting point for investigation. Armed with this insight, the revenue cycle team was able to drill down into the data, isolate the issue, and understand its connection to payer requirements.

Outcome

The analysis revealed that the surge was caused by a payer rule change requiring prior authorization for outpatient therapy services. Most of the denials traced back to claims submitted after mid-September and tied to CPT code 97110. With this knowledge, the client promptly informed PT clinics of the new requirements, updated internal processes, and prevented further denials from occurring. As a result, the practice not only protected significant revenue but also built stronger compliance practices to safeguard against similar payer-driven changes in the future.

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