Operations Clean Claims:
Provider Relations Strategy for Reducing Provider Denials
Summary: This article will show you how to perform an outreach program that can reduce provider denials, increase their first pass approvals, timely payments, and increase your relationship with your provider network, all at the same time, improving you and your provider's federal and statewide compliance in medical coding and payment compliance.
Caveat/Requirement: This article only helps your payer organization if you already have the Virtual Examiner Suite. If you need a demo or wish to explore VE, please click here.
How to Audit Providers Fairly
Stage 1: Let Providers Know Your New System
Email your providers and lead billing teams to let them know you are launching a system that will help them reduce denials, increase compliance, and speed up authorization approvals and payments. The system known as Operations Clean Claims is designed to help them and avoid costly audits that are being enforced on Medicare, Medicaid, and Medicare Advantage, both state and nationwide. Failure ot participate may result in increased denials and delayed payments.
Stage 2: Address Biggest Financial Losses
As a payer organization, it’s essential to avoid targeting individual or specific providers. Audits and denials must be applied equitably to all providers in accordance with established rules and contracts. From a provider relations perspective, the most effective approach is to generate VE reports to find out the five most significant financial losses currently arising from provider denials and non-compliance.
This report is now your 30-90 day corrective action, during which you are performing outreach to all providers on how to bill this code correctly. From there, you can create emails to all providers of this "growing trend" and, as their provider relations contact, you wish to schedule a short 20-30 minute video call with their billing team and/or providers to help reduce denials and increase the speed at which your organization can pay out claims with state and/or federal compliance.
Key benefits of this approach for providers
Immediate visibility into denial risk: VE reports help providers see the patterns behind their denied or delayed claims before they escalate.
Proactive correction opportunity: Providers can make adjustments to documentation or workflows early—before claims are submitted.
No blame, just data: This stage uses aggregate insights, not individual targeting, to invite collaborative improvement.
Supports cleaner claims: Early notification and insight help reduce downstream denials, rework, and appeals.
Key benefits of this approach for payers
Establishes a non-punitive first step: Framing Stage 1 as an advisory alert encourages providers to self-correct, avoiding adversarial dynamics.
Reduces unnecessary abrasion: By focusing on top denial drivers across the network, payers can address issues without singling out providers.
Faster lift for high-volume errors: Many early-stage denials stem from a few preventable causes—resolving these lifts claims performance quickly.
Sets foundation for education: Stage 1 prepares providers for targeted coaching in Stage 2 if patterns persist.
Stage 2: Address Biggest Compliance Risks
As a payer organization, it’s essential to avoid targeting individual or specific providers. Audits and denials must be applied equitably to all providers in accordance with established rules and contracts. From a provider relations perspective, the most effective approach is to generate VE reports to find out the five most significant financial losses currently arising from provider denials and non-compliance.
This report is now your 30-90 day corrective action, during which you are performing outreach to all providers on how to bill this code correctly. From there, you can create emails to all providers of this "growing trend" and, as their provider relations contact, you wish to schedule a short 20-30 minute video call with their billing team and/or providers to help reduce denials and increase the speed to which your organization can pay out claims with state and/or federal compliance.
Key benefits of this approach for providers
Clear guidance on what to fix: VE reporting highlights specific CPT, ICD, or modifier issues driving the provider's denials.
One-on-one consultation support: Provider reps can schedule brief calls with billing or coding staff to walk through examples.
Faster reimbursement with fewer denials: Corrective action tied to real data means fewer denied claims and less time spent reworking submissions.
Strengthened payer-provider trust: Approaching compliance and coding concerns with transparency and structure reinforces a collaborative relationship.
Key benefits of this approach for payers
Focused outreach with measurable ROI: Engaging providers tied to the highest denial costs ensures corrective action where it matters most.
Demonstrates equitable enforcement: Applying the same process to all providers—even if just the top 5 codes—shows consistency and compliance integrity.
Supports audit defensibility: Showing that proactive outreach occurred before audits supports a payer's good faith efforts in oversight.
Reduces repeat errors: Patterns addressed in Stage 2 often lead to sustainable improvements in provider billing accuracy and claim acceptance.
Stage 3: Counsel and Empower
Healthcare professionals, including doctors and nurses, are dedicated to treating patients and receiving compensation for their services. To enhance this process, it's essential to first resolve any issues they encounter with their billing staff, and then equip them with the tools to address these billing challenges independently. Ultimately, your role as a payer is to approve or deny claims, make payments as they stand, reduce amounts, or decline payment altogether. However, you have the opportunity to take it a step further by positioning yourself as a partner in healthcare rather than merely functioning as a financial institution.
Show clinics how to find their own errors
You already ran the report for them, but your data is only for your plan; they may be taking on additional lines of business and insurance. Your goal is to have them become as resourceful and independent as possible. The more they review their claims and earnings, the more they can have the power that many providers state they have lost in recent years.
Most Denials by Category:
- Log in to their billing software and run a 6-month denial report.
- Filter by the most denials per code.
Most Denials by Loss:
- Repeat, but filter for claim value.
Offering iVECoder to your providers
If and when you perform onsite audits of providers, you can bring a tablet along with you and showcase how VA gives you the ability to research codes, run mock claims and auths, and then offer iVECoder to them at a highly discounted rate to address the top 3-5 coding errors every 90 days and improve their approval rates. By using iVECoder only for claims that contain 99386, they can enhance first-pass authorization and claim payment approvals in as little as a week.
Helping billers focus and spend more time on documentation
IVECoder doesn't have their patient billing and clinical history; it's just a code scrubber, so they will need to use the extra time they now have to look at the #1 reason for denials: insufficient, missing, or incorrect documentation.
AI Integrations to Analyze Your Data
We included our denial spreadsheets below; you can update them in Excel or Google Sheets as you see fit. You can also have AI help you build, manage, and even interpret them. The Denial Savings Scoreboard works seamlessly with AI assistants like Microsoft Copilot for Excel or Google Gemini for Sheets, so your team can:
- Summarize the top 5 denial drivers by provider.
- Generate call scripts for coding consults.
- Forecast payment improvements by correcting code-level errors
- Auto-fill historical CPT patterns from prior quarters
If your plan uses analytics platforms or business intelligence tools, this spreadsheet can also be integrated into dashboards or imported into SQL-based claims analysis.
PHI Disclosure: Make sure that before you upload anything into an AI platform you "de-identify" the patient information as to remain compliant with HIPAA. Stick to provider ID numbers and codes.
How to use the Denials Dashboard Sheet
This dashboard helps you quantify the cost of denials for a specific provider or CPT code over time. To get started, enter the provider’s name (or the code you want to track) in the top row of the sheet. Then, input their quarterly data — including the number of denials, total charges, and associated costs for each of the last 4 quarters. The sheet automatically calculates the average daily denial volume, total annual financial impact, and trend lines over time.
This tool is ideal for provider relations teams during on-site or virtual consults. You can use it to show how even modest reductions in denials can improve payment speed and cash flow. It also pairs well with AI tools like Microsoft Copilot or Google Gemini, which can help auto-summarize trends, create provider-specific action plans, or forecast future savings based on changes in coding or pre-auth workflows.
Added Bonus Download Below: I've included a fillable PDF so you can quickly fill out information, or your providers can, and calculate the savings your efforts and iVECoder are making for both of you.
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About PCG
For over 30 years, PCG Software Inc. has been a leader in AI-powered medical coding solutions, helping Health Plans, MSOs, IPAs, TPAs, and Health Systems save millions annually by reducing costs, fraud, waste, abuse, and improving claims and compliance department efficiencies. Our innovative software solutions include Virtual Examiner® for Payers, VEWS™ for Payers and Billing Software integrations, and iVECoder® for clinics.
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