Medical billing is a crucial part of healthcare, ensuring that providers get paid and patients don’t face unnecessary costs. However, many claims get denied due to simple errors or overlooked steps. Understanding the common reasons behind denials in medical billing can help you fix issues faster and avoid future problems.
In this blog, we’ll go over the top 7 reasons medical claims get denied and offer easy solutions to resolve them. This will help you better understand the denial process in medical billing and make your claims more successful.
1. Incorrect or Incomplete Patient Information
One of the most common reasons for denial in medical billing is wrong or missing patient details. A single typo in the patient’s name, insurance ID, or date of birth can cause the claim to be rejected.
❌ Example:
Entering “John Smith” instead of “Jon Smith”
Typing the wrong insurance number
✅ How to Fix It:
Double-check all patient information before submitting the claim.
Use an automated system or software that flags incomplete or inconsistent data.
Keep a checklist for front-desk staff to verify insurance details during patient check-in.
2. Invalid or Expired Insurance Coverage
If a patient’s insurance is no longer active on the date of service, the claim will be denied. This happens often when coverage changes, especially at the start of a new year.
❌ Example:
Claim submitted for a date when the patient’s policy had already lapsed.
✅ How to Fix It:
Always verify the patient’s insurance eligibility before the appointment.
Use real-time eligibility tools or contact the insurance provider directly.
Inform the patient immediately if their coverage is not valid.
3. Missing or Incorrect Codes
Billing codes such as CPT, ICD-10, or HCPCS must be accurate and appropriate for the treatment provided. Any mistake in coding can result in a denial.
❌ Example:
Using a code that doesn’t match the diagnosis or procedure
Outdated or deleted codes
✅ How to Fix It:
Ensure your medical coders are trained and up to date on the latest codes.
Use coding software that updates regularly.
Always cross-reference diagnosis and treatment to ensure accurate coding.
4. Services Not Covered by Insurance
Sometimes, the treatment or procedure isn’t covered under the patient’s policy. Submitting a claim for a non-covered service will lead to denial.
❌ Example:
Billing for cosmetic surgery under a basic insurance plan
✅ How to Fix It:
Check the patient’s plan to confirm what services are covered.
If necessary, obtain prior authorization before providing the service.
Inform the patient about any services that may not be covered and offer alternatives.
5. Lack of Prior Authorization
Many insurance providers require prior approval before certain treatments or procedures can be billed. If this step is skipped, the claim will be denied.
❌ Example:
Performing an MRI without getting prior authorization
✅ How to Fix It:
Know which procedures require pre-authorization by each payer.
Create a system to track and request approvals ahead of time.
Keep records of all authorization numbers and communications.
6. Duplicate Claims
Submitting the same claim more than once can lead to automatic denial, even if it was unintentional.
❌ Example:
Accidentally submitting the same bill due to a system error
✅ How to Fix It:
Carefully review your billing history before sending claims.
Use software that flags duplicates.
