Uncovering the Root Cause: Using the 5 Whys Method in Denial Management
- Alicia Shickle
- Apr 7
- 2 min read
When it comes to denial management in healthcare, surface-level solutions don’t cut it. If your practice is seeing the same denials over and over — even after staff retraining or claim resubmissions — you may be treating the symptoms without addressing the root cause.
That’s where the 5 Whys Method comes in.
🔍 What Is the 5 Whys Method?
The 5 Whys is a simple but powerful tool from the world of process improvement and Lean thinking. It works like it sounds: you start with a problem — in this case, a denial — and ask “Why?” five times (or more) until you reveal the true source of the issue.
This technique helps teams move beyond quick fixes like “We’ll try harder next time” or “We just missed that one,” and instead develop targeted solutions that actually stick.
📅 When Should You Use It?
The 5 Whys Method is especially useful in situations where:
You're seeing repeat denial codes for the same types of services
Your team is unclear on the root cause of a denial
You're preparing for a compliance audit or internal review
Denials are affecting revenue cycle performance or staff morale
You want to foster a culture of continuous improvement
It’s also a great way to build compliance awareness into operational workflows — helping your staff think more critically about the "why" behind every task.
🏥 Example: The CO-16 Denial
Let’s say your billing team receives a CO-16 denial — claim lacks information needed for adjudication.
Instead of immediately resubmitting, you dig deeper:
1. Why was the claim denied?→ Required clinical documentation was missing.
2. Why was the documentation missing?→ It wasn’t uploaded with the claim.
3. Why wasn’t it uploaded?→ The billing team didn’t know it was required by this payer.
4. Why didn’t they know?→ There’s no checklist for payer-specific documentation.
5. Why is there no checklist?→ The practice lacks standardized training and tools.
✅ Root cause: The issue isn’t just a one-off oversight — it’s a process gap in how the team is trained and supported.
💡 Why It Matters
When your team uncovers the real “why” behind a denial, you gain the power to prevent it in the future — not just fix it once. That’s a win for your revenue cycle, your compliance program, and your culture of accountability.
📥 Want the Full Guide?
Our new free resource dives even deeper into how to implement the 5 Whys in your practice.
It includes:
A spot-check denial management template
A realistic case scenario for microlearning
The printable one-page 5 Whys Educational Resource
🎯 Whether you’re a compliance lead, office manager, or billing coordinator, this tool will help you go from reactive to proactive in denial management.
Need help training your team on how to spot patterns in denials or use this in your compliance huddles? We’re here to help. Reach out or follow us for more tools that make compliance doable.
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