Top 7 Reasons Medical Claims Get Denied and How to Prevent Them
Claim denials are the silent drain on a practice’s revenue. Even a small increase in denials can heavily impact cash flow and profitability.
Understanding the root causes and fixing them early is the key to steady collections.
- Incorrect or Missing Patient Information
Even small errors (DOB, policy number, address) can trigger a denial.
Solution:
Verify patient eligibility before every visit even for follow-up appointments.
- Incorrect Coding or Missing Modifiers
Coding mistakes are one of the top reasons for denials.
Solution:
Stay updated on CPT, HCPCS, ICD-10, and modifier changes. Use certified coders or outsource coding.
- Prior Authorization Not Obtained
Many payers deny claims simply because the service was not pre-authorized.
Solution:
Set up a pre-authorization checklist for high-risk services and specialty procedures.
- Duplicate Claims
Submitting the same claim multiple times results in instant denial.
Solution:
Use a billing system that flags duplicates and batches claims correctly.
- Lack of Medical Necessity
If documentation doesn’t support the service, payers will deny it.
Solution:
Accurate documentation + coding that reflects the medical necessity.
- Filing Claims After the Timely Filing Limit
Most insurances have 90–180-day limits.
Solution:
Submit all claims within 24–48 hours of service.
- Eligibility or Coverage Expired
Plans change every year or sometimes mid-year.
Solution:
Real-time eligibility verification before each service.
Final Thought:
Denials can’t be eliminated but with a structured process, you can reduce them dramatically and improve your practice’s cash flow.