SUCCESS STORIES

Prevent denials from diminishing revenue.

Identify + resolve root cause issues causing costly denials.

We help providers stay ahead of denials.

Successful denial management requires an end-to-end view of the revenue cycle. We identify and resolve upstream issues to prevent downstream impact.

first-pass denial rate

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final denial write-offs as % of NPR

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better DRG + coding accuracy

0 %

Ensemble Innovation

EIQ for clinical denial prevention

Clinical denials routinely put millions of dollars at risk for large health systems. EIQ^® helps ease the burden by reading the medical record in seconds, identifying denial risk with clear rationale and actionable recommendations — right in existing processes.

“Ensemble’s team has a degree of focus and commitment to overturning every stone with a diligence and thoroughness you simply don’t see with a lot of other partners across the revenue cycle.”

SVP, Revenue Management

Southeastern Health System

OUR RESULTS

Ensemble’s predictive AI reduces outpatient prior auth denials by 30%.

Prior authorization denials are a major source of lost revenue for providers, and preventing or reversing them is an ongoing challenge. Rules-based approaches struggle to keep pace with constant payer updates and robotic process automation breaks with monthly payer portal changes.

In response, Ensemble developed and implemented AI to predict and prevent prior authorization denials based on real payer behavior. Within 5 months, pilot hospitals reduced outpatient prior authorization denials by 30%.

Here’s how it works:

Scores all outpatient accounts on a 1–100 denial risk index to predict likelihood an authorization is required and likelihood of denial based on the payer and service
Flags high-risk accounts prior to date of service for second-level review
Dynamically re-scores accounts as payer rules or procedures change
Predicts common associated codes for proactive authorization based on the primary procedure

CLIENT SNAPSHOT

84% denial reduction doubles hospital wound care capacity.

A large faith-based health system faced high denial rates for specialized outpatient services. Ensemble pinpointed root cause issues, optimized authorization workflows, strengthened clinical documentation and educated staff. The results — an 84% reduction in first-pass denials and a 4.2% denial reduction systemwide. The additional revenue from accurate insurance payments funded two new specialty medical devices, doubling patient treatment capacity at a wound care center.

CLIENT SNAPSHOT

Community health system lowers first-pass denials by 43%.

A 7-hospital system engaged Ensemble for end-to-end revenue cycle managed services after poor financial performance threatened its ability to meet the needs of its community.

Ensemble transitioned and upskilled the system’s staff, filled talent gaps, streamlined processes and applied proprietary AI to catch errors before they resulted in denials. The system saw a 43% reduction in first-pass denials and 44% decrease in AR aged over 90 days.

"We chose Ensemble many years ago because of their reputation. We were getting lots of denials, and claims weren't going out as clean as they needed to be. Our hands were tied regarding how we could fix that."

Health System CEO / President

May 2025, KLAS Research Interview

"Ensemble is investing in AI. They have asked us for a direct feed of clinical information so that they can do what the payers are doing from an AI perspective in reverse and try to look at combating things, having fewer denials and downgrades, and being proactive on where their gaps are.”

Health System CFO

March 2025, KLAS Research Interview

"We did a study comparing a set of claims in the review process through Ensemble's AI review program and the outside group's program. Ensemble's program caught everything on the DRG review that the physician group's program caught, but Ensemble also caught another percentage of charts that the physician group missed.”

Health System CFO

March 2025, KLAS Research Interview

CLIENT SNAPSHOT

Physician practice group reduces denials by 48% with end-to-end partnership.

Facing increasing financial pressure, a 10-clinic system engaged Ensemble for end-to-end revenue cycle management based on a referral from its community connect partner. Here’s how we helped:

Clinical denial appeals

Clinically trained denials specialists exhausted all appeal and recovery efforts

Cash acceleration

Strengthened charge capture and denial follow-up for $550K increase in monthly collections

Ongoing training

Established regular reporting, communication and training for practice alignment

CLIENT SNAPSHOT

10-hospital system recovers $5M missed by existing vendors.

Despite working with multiple underpayment vendors, a southeastern health system felt it was missing out on revenue opportunities and wanted a more tactical, hands-on approach. It engaged Ensemble to perform a deep dive into its accounts to recover revenue and prevent future underpayments.

Ensemble deployed AI to eliminate false variances and detected anomalies missed by others and applied best practices to recover $5 million and prevent $1.5 million in underpayments annually.

CLIENT SNAPSHOT

Ensemble’s secondary zero-balance review yields $13M in recoveries.

A Midwest health system needed a secondary partner to focus on an opportunity untouched by its primary vendor: zero-balance accounts.

Resolved rev code errors

Billing edits resolved revenue code errors that were causing millions in underpayments

Prevented underpayments

Predictive AI and anomaly detection identified and prevented $20M+ in underpayments

Led contractual disputes

Identified and disputed > $6M in underpayments based on contract language for implants

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