Top 10 Reasons Claims Get Denied — And How to Prevent Them

Claim denials are one of the biggest threats to any medical practice's financial health. According to industry data, US healthcare providers write off over $125 billion in denied claims every year — most of which could have been prevented. Understanding why claims get denied is the first step to stopping it.

The Top 10 Reasons Claims Get Denied

1. Missing or Incorrect Patient Information

Simple data entry errors — wrong date of birth, misspelled name, incorrect insurance ID — are responsible for a significant portion of all denials. These are entirely preventable with proper eligibility verification at check-in.

2. Eligibility and Coverage Issues

The patient's insurance was inactive on the date of service, or the service is not covered under their plan. Always verify eligibility before the appointment, not after.

3. Duplicate Claims

Submitting the same claim twice — even accidentally — triggers an automatic denial. Your billing software should flag duplicates before submission.

4. Incorrect or Missing Diagnosis Codes

Using an unspecified ICD-10 code when a more specific one is available, or linking the wrong diagnosis to a procedure, will result in denial. Certified coders catch these before submission.

5. Procedure Not Covered

The service rendered is excluded from the patient's plan or requires prior authorisation that was not obtained. Always check benefit details for high-cost or elective procedures.

6. Missing Prior Authorisation

Many payers require pre-approval for certain procedures, specialist visits and medications. Failing to obtain authorisation before the service is provided almost always results in denial.

7. Timely Filing Violations

Every payer has a deadline for claim submission — typically 90 days to 1 year from the date of service. Missing this window means the claim is denied and often cannot be appealed.

8. Bundling Errors

Billing separately for procedures that should be billed together (or vice versa) violates payer bundling rules. This requires up-to-date knowledge of CPT bundling guidelines.

9. Coordination of Benefits Issues

When a patient has multiple insurance plans, claims must be submitted in the correct order. Sending a claim to the secondary payer before the primary has processed it leads to immediate denial.

10. Credentialing Problems

If a provider is not credentialed with the payer, or their credentials have lapsed, every claim they submit will be denied. Keeping credentialing current is non-negotiable.

How to Prevent These Denials

• Verify patient eligibility in real time before every appointment
• Use certified coders who stay current with ICD-10 and CPT updates
• Implement a claim scrubbing process before every submission
• Track authorisation requirements for every payer you work with
• Monitor your timely filing deadlines with automated alerts
• Audit denied claims monthly to identify and fix recurring patterns

The good news is that most denials are preventable. A robust Revenue Cycle Management process — with proper eligibility verification, certified coding and pre-submission scrubbing — eliminates the majority of these issues entirely.