Denial Intelligence

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What you're looking at

This shows what's driving your denied claims, which payers are driving this, and how your denial rate compares with peers.

Denials can quietly erode revenue you were expecting to collect, and it's easy to lose track of the pattern when they're scattered across statements from different payers. Bringing them into one place makes it easier to spot what's actually driving the loss, and if there is something that can be done about it, instead of noticing it one denial at a time.

How it's calculated

See What You Need to Know About Medical Claims for additional background knowledge

Common denial reason categories: The 9 most common denial reasons are grouped into categories so you can quickly see where most of your denials are coming from. Everything else falls under ‘Other’.

All claims must be fully adjudicated: Claims that are pending or under appeal are not included in your total claims count used to calculate your denial rate.

Only fully denied claims are considered denied: Partially denied claims that were paid but had an individual service line denied are excluded from your denied claims total, but still used in your total claim count.

12-month rolling window: Analyzing real-world data claims from the past 12 months of your practice, to stay current while having enough volume to track recurring trends. The window updates as new remittance data lands.

Denial reasons are based on CARC Codes: See the actual Claim Adjustment Reason Code that caused your claims to be denied, grouped into the most common categories by volume.

Peer comparisons at the local level: See how your denials compare to other providers in your specialty and geographic area. Jiro starts with the geography that best reflects your actual practice area, usually your CBSA (Core Based Statistical Area, used by CMS for billing adjustments), county or state to give you an accurate comparison. See how we build your peer comparison group for more.

Peer denial rates are averages: Your denial rates are compared to the average rate among your peer providers. This is compared for all causes, specific denial categories and specific payers.

Billed charges only: Dollar amounts reflect billed charges, not what your contracted rate with each payer would actually pay out, so the real recoverable amount is typically lower. For a deeper look at contracted rates, see the Negotiated tab under Reimbursement Intelligence.

Gaps in remittance data: Jiro does not have denial information on all of the claims we receive, so some denials may not be present in your dashboard. For this reason, shown volumes may be an underestimation.

Only submitted claims are counted: Activities or procedures that never occurred because of prior authorization denial are not captured in our claims data, and therefore not present in your totals.

How to read this

The Denied Claims Value dollar figure at the top of the page is the total amount you have missed due to denials.

Your All Cause Denial Rate is the percentage of your total claims that were fully denied, with your peers average depicted below.

The Highest Denial Rate line names both a payer and a reason, which makes it a good starting point since it's specific enough to act on directly (a timely-filing pattern with one payer is a very different fix than a documentation gap on a specific procedure).

The Pie Chart breaks down your denials share by category. Hovering will show the CARC code associated with that category, along with other information shown in the breakdown.

The Denial Breakdown table is ranked by total dollar impact, with "Other" last, so the biggest patterns surface first. In the table:

• Category rows are shown at the top level. Your Denial Rate percentage for each category row is your total denied claims in that category, divided by your total claims.

Your Denial Rate (%) = (Denied Claims in Category ÷ Total Claims) × 100

• Subline rows are found under the dropdown of each category, showing every Payer who denied you within that category. Your Denial Rate for each payer row is the total claims that payer denied for this category, divided by your total number of claims with that payer overall.

Your Denial Rate (%) = (Claims denied by this payer for this reason) ÷ (Your total claims with this payer) x 100

• Therefore, percentages in the payer sublines of categories will not add up to the total percentage for that category, because they are using different denominators (payer specific total vs all claims total)

If your denial rate is above peers, that's a prompt to look closer, not a verdict. A higher rate can come from your payer mix, your patient population, or something as specific as a documentation habit with one payer, not necessarily anything wrong with how you're billing. The comparison is a benchmark meant to point you toward where to look.

If "Other" makes up a large share of your denials, expand that row to see which payers are driving it. Codes in this category vary and don't occur frequently enough to warrant their own category, so the specific reason isn't shown here. A concentrated pattern among specific payers is worth raising with whoever handles your billing.

Common questions

I don't see any data at all. What's going on?

This may happen for several reasons. The most likely reason is that your denied claims were not captured in Jiro’s database, so they aren’t shown on your dashboard. It’s also possible you  don't have enough denied claims in the current 12-month window yet. Both resolve as more of your claims data comes in.

These peers don't look like my practice. Are you sure this is who you're comparing me to?

If the group feels off, check that your specialty is set correctly in your profile, that's what drives the match.

Why does this only cover a rolling 12 months?

It keeps the window current with your practice while still holding enough volume for the peer comparison to mean something.

How current is this?

The numbers you see are representative of 9 full months of data. Although the window shows your 12 most recent months of activity, Denial Intelligence requires both remittance data and the original claim, which is usually subject to at least 3 months of claims lag before Jiro receives them. While some data included may be recent, your numbers will be driven by the first 9 months of the shown time window.

I don't handle my own billing. What should I do with this?

That's completely fine, plenty of clinicians don't. This still gives you a clear starting point you may not have had before. If a payer or reason category looks worth a second look, bringing the CARC code(s) to your billing department may help identify where the issue lies.

Limitations

• Not all claims that Jiro receives have remittance data. Shown volumes may be an underestimation of your total denials.
• Claims are attributed to the NPI of the billing provider listed on claims. If you bill under someone else’s NPI (e.g. a resident under an attending) your claims will be attributed to that provider. Similarly, if someone in billing under your NPI, their claims will be attributed to you.
• Only fully denied claims are counted. A claim with one denied service line and the rest paid isn't reflected as a denial here.
• Dollar amounts reflect billed charges, which may be higher than the amount that could actually be recovered.
• Only professional claims are included; institutional or facility claims aren't reflected here. The dollar amounts you see are for what you personally bill, not what your institution bills.

Still need help?

Reach out to support using the help button in the app or by emailing support@jirohealth.com