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Common Reasons Medical Claims Get Rejected.

June 28, 2016


What’s your claims denial rate? Some of the most recent benchmarking data for family practice groups suggests an average of 5 to 10%, while the AMA found that Medicare rejects roughly one in 20 claims. No matter where you fall in the denial rate spectrum, however, denied claims leave cash on the table that can impact your profit margin significantly if they aren’t managed properly. 

If your rejections are out of control, take a look at these common culprits that lead to denials. 

Timing Issues

Timing is everything when it comes to medical billing. Are you watching for these important dates when you file your claims?

  • Filing after the claims deadline (usually 60 to 90 days).
  • Using an expired authorization or referral, or providing services before the authorization was approved. Check dates carefully; some authorizations expire in as little as 30 days. It’s also important to make sure you haven’t exceeded the number of authorized visits or services to avoid denials.

Registration Issues

Your front desk is the front line in successful medical billing, so make sure your staff aren’t making these avoidable errors:

  • Failing to verify coverage/enrollment status before services are rendered.
  • Not updating insurance information in the EHR so claims are sent to the correct carrier and address.
  • Neglecting to check requirements and benefits for in-network versus out-of-network providers.
  • Failing to obtain a valid referral or prior authorization when necessary.

Related Article: 5 Ways To Improve Your Medical Claims Reimbursements

Coding Issues

This is one of the stickiest areas for inexperienced billing departments; coding and documentation requirements can vary significantly and lead to delays, rejections, and requests for additional information, slowing up reimbursement. Watch these trouble spots:

  • Diagnostic and procedure code mismatch.
  • CPT code and location code mismatch (using an outpatient procedure code with an inpatient locator).
  • Services are provided at an unregistered location. 
  • Provider is not paneled with the insurance company (be careful with carriers with multiple panels within a single company, such as an HMO and PPO).

If you’re missing the mark with your denial rate, contact the billing professionals at M-Scribe today. We’ll show you ways to improve your collection rate and boost your bottom line.


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