Top 5 Reasons Medical Claims Get Denied — and How to Stop the Revenue Bleed
If claim denials feel like a never-ending game of whack-a-mole, you’re not alone. A recent MGMA Stat poll found that 60 % of medical group leaders saw higher denial rates in 2024 than in 2023 — even as patient volumes stayed flat. Lost revenue, rework costs, and patient dissatisfaction all pile up when denials climb.
Typos in names, outdated policy numbers, or coordination-of-benefits mix-ups lead to an immediate CO-16 denial. Even a missing middle initial can trigger rejection. Tip: verify demographics and eligibility before the patient leaves check-in.
2. Missing Prior Authorization
Nearly half of denials in a 2023 Experian survey were linked to authorization gaps according to experian.com. Build an auto-alert list of CPT codes that always require prior auth and integrate it into your scheduling script.
3. Coding & Modifier Errors
From wrong laterality to mismatched diagnosis-procedure pairs, coding misfires account for 42 % of denials in hospital systems according to beckershospitalreview.com. Regular coder education and pre-bill scrubbing software can prevent these hidden landmines.
4. Insufficient Medical-Necessity Documentation
Payers deny services they deem “not medically necessary.” Make sure every claim is backed by problem-oriented notes, clear ICD-10 specificity, and supportive labs or imaging.
5. Late Filing or Timely-Filing Limit Exceeded
Most payers allow 90–365 days, but some Medicaid plans cut that to 30 days. Set up automated “days-since-DOS” counters so nothing slips past the deadline.
Bottom Line
Every denied claim costs an average $42.84 in rework, and up to 65 % are never resubmitted according to techtarget.com. Tackling the five issues above can reclaim thousands in revenue each month.
Need expert help? Schedule a complimentary Denial Analytics Review with Matrix Medical Billing and discover how our 99 % clean-claim process can safeguard your bottom line.
