Denied claims can be a major roadblock to consistent revenue for healthcare providers. Every denial means delayed payment, extra administrative work, and potential loss of income. But the good news? Most denials are preventable. At EZ MedBill, we’ve seen firsthand how simple process improvements can significantly reduce denial rates. Below, we break down the top 10 reasons medical claims get denied and offer practical tips to avoid them.
1. Incorrect Patient Information
The Problem: Typos or outdated information (e.g., insurance ID, date of birth) can trigger instant rejections.
The Fix: Verify patient information at every visit. Use real-time eligibility checks to catch issues before claims are submitted.
2. Missing or Invalid Authorization
The Problem: Some services require pre-authorization. If it’s missing, the claim is likely to be denied.
The Fix: Build a pre-authorization checklist by procedure or payer. Train staff to flag services needing approval before scheduling.
3. Services Not Covered by the Payer
The Problem: If a service isn’t part of the patient’s insurance plan, the claim will be denied.
The Fix: Conduct eligibility verification before treatment. If coverage is unclear, consider getting a signed waiver for non-covered services.
4. Coding Errors
The Problem: Inaccurate or outdated CPT, ICD-10, or HCPCS codes lead to denials or downcoding.
The Fix: Ensure coders stay updated on coding changes. Use certified medical coders and double-check complex or high-value claims.
5. Lack of Medical Necessity
The Problem: Payers may deny claims if documentation doesn’t support the diagnosis or treatment.
The Fix: Improve clinical documentation and link every procedure to a medically necessary diagnosis. Use E/M templates if needed.
6. Duplicate Claims
The Problem: Accidentally submitting the same claim more than once often results in automatic rejection.
The Fix: Use billing software with built-in duplicate claim detection. Train staff to check claim history before resubmitting.
7. Timely Filing Issues
The Problem: Every payer has a deadline for submitting claims. Miss it, and payment may be permanently forfeited.
The Fix: Set internal filing deadlines well before the payer cutoff. Automate reminders for resubmissions and appeals.
8. Out-of-Network Provider
The Problem: Claims may be denied or reimbursed at lower rates if the provider is out-of-network.
The Fix: Verify network status during scheduling. Consider credentialing with frequently used payers to reduce denials.
9. Mismatched Place of Service Codes
The Problem: Incorrect place-of-service (POS) codes can confuse payers and lead to denials.
The Fix: Ensure billing staff understand which POS codes align with your care settings telehealth, in-office, hospital, etc.
10. Insufficient Documentation
The Problem: Missing progress notes, signatures, or operative reports can trigger denials.
The Fix: Audit clinical notes regularly. Use digital tools and templates to standardize documentation across providers.
Final Thoughts: Prevention Is Profit
Reducing claim denials doesn’t just improve your cash flow it streamlines your operations, reduces staff burnout, and strengthens your bottom line.
At EZ MedBill, we help practices identify denial trends, correct systemic issues, and implement smarter billing processes. If denials are hurting your revenue, we’re here to help you fix it for good.
Ready to reduce your denial rate?
Contact EZ MedBill for a free RCM consultation today.
