Top 10 Reasons for Claim denials & How to fix them
Claim denials are a $262 billion problem for healthcare providers, with up to 40% of denials left unworked due to resource constraints. For many practices, fixing preventable billing errors could recover 5-10% of lost revenue annually.?
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At Med Reimburse Partners LLC, we’ve analyzed thousands of denials across specialties. Here are the top 10 culprits we see—and proven strategies to resolve them:?
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1. Incorrect Patient Information?
Denial Reason: Typos in names, DOB, or insurance ID numbers.?
The Fix:?
Implement real-time eligibility checks during patient intake.?
Train front-desk staff to scan insurance cards at every visit.?
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2. Missing/Invalid Authorization?
Denial Reason: Prior authorization not obtained or expired.?
The Fix:?
Use automated tracking tools to flag expiring authorizations.?
Create specialty-specific checklists for procedures requiring pre-approval.?
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3. Coding Errors (CPT/ICD-10 Mismatches)?
Denial Reason: Codes don’t align (e.g., ICD-10 doesn’t justify CPT).?
The Fix:?
Audit charts for documentation gaps before coding.?
Get the help from experienced coder of your specialty.
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4. Duplicate Claims?
Denial Reason: Accidentally resubmitting the same claim.?
The Fix:?
Integrate claim scrubbing software to flag duplicates pre-submission.?
Standardize processes for tracking claims in “pending” status.?
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5. Late Filing?
Denial Reason: Submitting claims past payer deadlines (often 90-180 days).?
The Fix:?
Set automated reminders for payer-specific filing windows.?
Outsource to a billing partner (like us!) to ensure timely submissions.?
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6. Non-Covered Services?
Denial Reason: Service isn’t covered under the patient’s plan.?
The Fix:?
Verify coverage before delivering care—never assume!?
Provide patients with Advanced Beneficiary Notices (ABNs) for elective services.?
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7. Missing Modifiers?
Denial Reason: Forgetting -25 (separate E/M) or -59 (distinct procedure).?
The Fix:?
Train coders on modifier logic for common scenarios.?
Use a modifier lookup tool integrated with your EHR.?
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8. Incorrect Place of Service (POS) Codes?
Denial Reason: POS doesn’t match the payer’s requirements (e.g., telehealth).?
The Fix:?
Update your team on 2024 POS guidelines, especially for virtual care.?
Crosswalk POS codes with payer-specific policies.?
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9. Inadequate Documentation?
Denial Reason: Notes don’t support medical necessity.?
The Fix:?
Provide physicians with templates linking common diagnoses to documentation requirements.?
Conduct quarterly random audits to catch compliance risks early.?
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10. Payer-Specific Rule Changes?
Denial Reason: Missing updates to local coverage determinations (LCDs).?
The Fix:?
Subscribe to payer newsletters and CMS email alerts.?
Partner with a billing team (like ours) that monitors policy changes 24/7.?
The Bottom Line?
Most denials are preventable with proactive systems, staff education, and technology. But if your team is drowning in paperwork or playing “denial whack-a-mole,” it might be time to call reinforcements.?
?Med Reimburse Partners specializes in:?
#MedicalBilling #RevenueCycleManagement #HealthcareProviders #ClaimDenials?
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