Resources / Denials

How to Reduce Claim Denials in a Medical Practice

High denial rates quietly drain cash flow. Many practices only notice the problem when A/R ages past 90 days or when monthly collections drop without a clear reason.

Most Common Denial Reasons

• Eligibility / coverage issues — patient was not eligible on the date of service, or the plan does not cover the service.
• Coding and modifier errors — incorrect CPT/ICD-10 pairing, missing or wrong modifiers, or outdated codes.
• Authorization problems — prior auth not obtained or not properly documented.
• Timely filing — claim submitted after the payer’s deadline.
• Documentation gaps — medical necessity not supported by the note.

Practical Steps You Can Take Internally

1. Run eligibility checks before every visit (not just new patients).
2. Review the top 10 denial reason codes every month and fix the process that causes them.
3. Create a simple charge-capture checklist so procedures and supplies are not left off the claim.
4. Track days in A/R by payer so aging problems surface early.
5. Make sure coders and providers communicate when documentation is insufficient.

When Outside Help Makes Sense

If denial rates stay above 5–8% after internal fixes, or if the same denial reasons keep repeating, it is often a sign that coding expertise or follow-up capacity is the bottleneck. A structured billing audit can show exactly where revenue is leaking before you decide to change staffing or outsource.