Why the Shift from Technical to Clinical Denials Matters with Chris Spady | Podcast Shorts from ArceeHQ

In this clip

Chris Spady explains how the denial landscape at Erlanger Health has shifted dramatically over the past decade, from roughly 85 percent technical denials to more than 50 percent clinical denials, fundamentally changing what it takes to win. Clinical denials bring a much longer runway, requiring cross-functional clinical teams and written appeals rather than straightforward revenue cycle corrections, and in many cases the fight is no longer about medical necessity but about care setting, specifically inpatient versus outpatient status.

Key Takeaway

The shift from technical to clinical denials means revenue cycle teams must build cross-functional clinical partnerships to win, because payers are increasingly refusing peer-to-peer reviews and written appeals carry a far lower success rate than peer-to-peer conversations did in the past.

“You have gone from a world where you are winning 70 to 80 percent of those peer-to-peers to where you have to fall back on the written appeal, which has a much lower win rate.”
Chris Spady, Senior Vice President of Revenue Cycle, Erlanger Health

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Chris Spady

Season 2 · Episode 6 · 44 min

Winning the Claims Denial War: Clinical Denials Management, Agentic AI, and the Ownership Mindset That Drives Results

Chris Spady · Senior Vice President of Revenue Cycle, Erlanger Health

Chris Spady brings a senior revenue cycle leader's perspective on why claims denial management is a permanent strategic initiative and why the shift from technical to clinical denials has fundamentally changed how health systems must respond. Drawing on experience across multiple major health systems and his return to Erlanger Health as Senior Vice President of Revenue Cycle, he explains the governance and operational layers his team uses to drive ownership throughout the organization, the benchmarking tools that provide apples-to-apples comparisons across health systems, and a workflow software implementation designed to ensure follow-up teams work the right accounts at the right time. Chris shares his honest view on agentic AI, why it is unlikely to eliminate the clinical denials management problem but represents a genuine opportunity for cost reduction and coding automation, and why the real opportunity in denials prevention lies not in chasing high-dollar claims but in systematically eliminating the thousands of low-dollar denials that drain staff resources. He closes with leadership lessons from a Navy SEALs masterclass on simplified decision-making and the ownership mindset he believes separates high-performing revenue cycle teams.

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Claims Denial Management, powered by agentic AI

How ArceeHQ catches denials before they happen, resolves them automatically, and gives your reviewers only the cases that need a human.

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Reducing claim denials with agentic AI

A practical framework for revenue cycle leaders. Covers the operating model shift, what to measure, and where automation actually pays.

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