08 May

Why are medical claims being denied?


Reworking denied medical billing claims is a significant part of revenue cycle management, which slows down cash flow. It’s important to proactively measure the volume and causes of denied medical billing claims so they can be prevented before they occur. Denials fall into two categories: hard and soft. Hard denials cannot be resubmitted or corrected and will result in lost (written-off) revenue. Soft denials are temporary and can be paid if the provider corrects the claim or sends additional information.


Here are some of the basic errors that can get a claim denied and returned to the biller.

  1. Incorrect information

Leaving just one required field blank on a claim form can trigger a denial. It’s estimated that over 60% of denials are a result of incorrect information. Incorrect patient information can include gender, name, DOB and insurance ID number. Incorrect provider information can include address, name and contact information. Incorrect insurance provider information can include a wrong policy number or address.

Incorrect codes, missing codes or mismatched medical codes. Entering confusing or conflicting codes, attaching conflicting or confusing, entering too few or too many digits to codes, or leaving out codes (missing codes).


  1. Duplicate billing

This happens when the provider’s office submits a claim for a procedure that has already been paid for/reported. Duplicates are claims that have been resubmitted for a single encounter on the same date by the same provider for the same beneficiary for the same service item, and are among the biggest reasons for Medicare Part B claim denials. It may appear that a patient received two identical services on one day, which would effectively double the amount sent to the payer.


  1. Not covered by payer

Medical billing denials for procedures not covered under patients’ current benefit plans can be avoided by checking details in the insurance eligibility response or calling the insurer before administering services.


  1. Limit for filing expired

Most payers require medical claims to be submitted within a certain number of days of service. Workflow should be setup to alert staff when medical claims are approaching the time limit. Reworking rejections for incorrect information or improper coding can cause delays that push medical billing past the deadline.


Learn how to reduce claim denials and rejections

Denials and Rejections

Written by Jason Gerber

As the Executive Vice President of Business Development, Jason provides the strategic leadership of the operational management team. This encompasses the oversight of all aspects of client account services, revenue cycle management, IS/IT services, and electronic health record/practice management deployment services. With more than 16 years in the industry, Jason has an in-depth working knowledge of full revenue cycle and is an active participant in national and regional FQHC/CHC trade associations.

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