To reduce claim denials, verify eligibility and authorizations before every visit, make sure documentation supports the codes billed, submit claims promptly, and review denials monthly by payer and reason so you fix the root causes instead of reworking the same errors.
By Bill For You RCM. Reviewed October 19, 2026. Payer rules change; confirm current requirements with each payer.
Start with the right numbers
- Denial rate: denied claims divided by claims submitted, tracked by payer, provider and reason code.
- Clean claim rate (first-pass rate): claims accepted and paid without correction or rework, divided by claims submitted.
- Days in A/R: total accounts receivable divided by average daily charges.
- Net collection rate: payments collected divided by the amount you were contractually allowed to collect.
Compare these against your own trend and against each payer, not a single industry figure, because specialty and payer mix change what is normal.
The most common causes of denials
- Eligibility and registration errors: inactive coverage, wrong subscriber details or a wrong payer on file.
- Missing or expired authorization: required prior authorizations or referrals not obtained or not matched to the service.
- Coding and modifier mistakes: codes that do not match the documentation, missing modifiers or unbundling issues.
- Documentation gaps: notes that do not support medical necessity or the time-based code billed.
- Credentialing problems: the provider is not enrolled with the payer or the effective date has not started.
- Timely filing and duplicates: claims sent after the payer’s deadline or submitted twice. Medicare, for example, generally requires claims within 12 months of the date of service.
A prevention workflow that works
- Verify eligibility and benefits before each visit, not just at the first appointment.
- Track authorizations by visit count and date range, and flag them before they run out.
- Capture charges quickly, ideally within a day or two of the visit.
- Review coding against documentation for high-risk services and new providers.
- Scrub claims with your clearinghouse or practice management edits before submission.
- Submit the same day documentation is complete wherever possible.
How to work a denied claim
- Read the denial reason and remark codes and confirm the deadline to respond.
- Decide whether it needs a correction or an appeal. Simple data errors usually need a corrected claim; medical-necessity and authorization disputes need an appeal with supporting documents.
- Appeal with specifics: cite the policy or contract language, attach the relevant records and state exactly what you are asking the payer to change.
- Log the reason so the denial feeds your monthly root-cause review.
- Escalate when a payer repeatedly denies the same service incorrectly.
Review denials every month
A short monthly review pays off: group denials by payer and reason, find the top three causes, assign an owner to each and check again next month. Repeating errors almost always trace back to one front-end step.
When it makes sense to get help
If denials are rising, A/R is aging or your team does not have time to work every denial, outsourcing can help. Read our comparison of in-house vs outsourced medical billing, or see how our denial management and A/R services work.