Every medical denial could potentially be lost money. Eventually, when those claims are covered, there are fees associated with that recovery that typically have to be taken off the patient’s revenue. Some studies show that medical billing denials can cost up to $118 per claim.

The most poignant thing about billing denials is that most often they are easy to avoid. Of course, everybody understands what the leading causes of medical billing denials are – the inability to pay for medical care. 

However, it is possible to prevent these losses altogether. It is essential that you already have some sort of a process that will help you identify and collect all of these errors and omissions ahead of problematic claim submission.

What is a medical billing denial?

Denials are claims for medical services submitted to an insurance plan that are deemed unpayable. Often medical denials can be due to insurance plan covered situations, and timely filing. Or the general limits of a person’s medical insurance coverage. 

A key difference between medical denials and rejections is that the biller cannot resubmit a denial. Instead, they need to be appealed, and appeals are costly. 

What is the most common reason for a medical bill in denial?

In most situations, with a medical billing denial, the patient is not eligible for the care under the terms of their health insurance plan. This means that the simple steps of doing an eligibility check before the patient is even seen by medical staff can prevent this issue from happening.

There are other regular reasons for Medical billing denials.

  • Duplicate billing, sometimes when a similar or equivalent claim is sent in clerical error, or an overlap in the office duties.
  • Outdated or improper ICD-10 or CPT codes. These codes determine what is paid, change quarterly. 
  • Insufficient information, even the smallest omission like date of birth can lead to a very expensive denial.
  • Out of networks, there are some plans that would require the doctor and practitioners to be in a network to provide coverage.
  • Untimely filing, as we only have so many girl days to file the claim.
  • Problems with modifiers, sometimes the result of submitting an invalid modifier combination. Invalid modifier combinations can be avoided when there is more care and better training for coding personnel. Or by only using a medical billing denial software. 
  • Prior authorization required, some payers want approval or other files from another position before the services can be performed.

Avoiding risks with the technology 

Medical billing, due to its complex nature, can put much pressure on practices as most are very unlikely to catch common areas; a number in the coding is incorrect, a date of birth is incorrect and other very small omissions. 

This is where technology can change everything you do. It can automate the updating of CPT code for you, and this will be practice-wide. Medical billing software will play a significant part in reducing the risk of outdated CPT code and billing denials.

With the right technology, you can also ensure that staff have guidance to make sure that they have looked at the patient’s eligibility before submitting it. Of course, the most important thing here is staff training and education, but having a framework to help guide them through the process should ensure that the right information will be collected and verified.

What steps can I take to improve my billing denial right?

Unfortunately, after the claim is denied, many medical practices often feel quite powerless. However, upon inspection, most billing denials are avoidable, so if you see that you have particular issues with particular codes, or not checking whether people are authorized for that care. You can then take steps to train your staff better in these areas. 

What’s more important is that you will also be streamlining your operations and save time.

Here are some quick tips on how you can make a difference in your medical billing claim denials.

  • Train and then test your staff to make sure that they recognize and can be vigilant around the key areas of the most often lead to denials
  • Audit your practice, and see if you are at risk of any of those most common denials.
  • Consider a revenue cycle management technology that can be integrated into your practice management system. This will help you to manage some of those aspects of the billing process.
  • Begin to benchmark your process, so you can see how much profit you can recoup by stopping all of those typical medical billing denials.


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