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What are the Top Most Reasons for Claim Denials in Medical Billing?

Let me share the story of “Alex”. He is a very knowledgeable medical practitioner. He has implemented very advanced technology and equipment to deliver quality patient care services. He provides quality care services to a huge volume of patients.

But still, he is unable to grow his business to new heights. Why? Because he has never paid attention to the non-medical obligations of a healthcare business. Like most small-sized or regular physicians do.

It is important to invest your valuable time and assets to streamline your business’s financial matters as well. A proper medical billing system allows healthcare providers to organize patients’ data and deal with their copayments and deductibles easily.

Along with resources, practitioners also need the right expertise and time to deal with insurance payers as well. It’ll help them to hit their business success goals in an optimized time. However, if they would neglect these areas of their healthcare business then would end up like “Alex”.

Now, the question here arises what is the best solution for proficient medical billing services? The answer is that like most successful healthcare businesses, you should also prefer to outsource medical billing company. 

In this way, you can get the professional assistance of medical billing specialists. Reliable medical billing companies have the essential equipment to process your medical claims accurately so they don’t stay unpaid due to denials and rejections.

Otherwise, if you would rely on your old and inefficient medical billing system then you would have to face the following problems that cause claim denials and boost revenue leakage ultimately.

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Unable to Identify Pre-authorization:

If your front desk staff does not responsibly verify the pre-authorization of a patient at the time of registration then they are inviting trouble right from the start.

It will not only cause complications for your medical billing staff while preparing medical bills but also hold your patients back from paying you off. Because, if you are not even assured whether to submit a medical claim to an authorized insurance payer or the patient, then you would be able to collect payment from the relevant payer.

Therefore, instead of neglecting this easy yet inevitable step, you should acquire help from professional medical billing and coding companies. Because they will provide you with innovative medical billing solutions that can help you capture accurate information in the right way.

Hence, they reduce your burden and the chances of claim denials as well.

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Incorrect Medical Codes:

This is the major reason for most medical claim denials or rejections. Healthcare practitioners shouldn’t take medical coding for granted and hire unqualified staff.

It requires in-depth knowledge and extensive experience to proceed with medical coding. For this purpose, practitioners can’t ask their medical staff to engage in billing and coding activities. Because it requires great dedication to collect, interpret and translate information into accurate medical codes.

Therefore, smart medical providers take wise decisions and partner with well-experienced medical billing and coding companies. In this way, they get in touch with a dedicated team of highly qualified medical coders. Who process their medical claims with great proficiency and make every claim such that it enforces payers to reimburse immediately.

Lag Behind the Deadline:

Different insurance companies have different deadlines for claim submission. When healthcare providers fail to follow the deadlines of a particular insurance payer then they lose a significant amount of revenue as well. Because their delayed claims get denied by those insurance companies.

Therefore, healthcare providers need dedicated resources that can manage the data about each individual payer. They follow up with the deadlines of every insurance company and submit claims at the right time.

In this case, there is no substitute for a well-developed medical billing solution and experts. Therefore, it is also the best option here to hire medical billing and coding companies.

Because they have all of it that is required to streamline your medical billing system for profitable results.

Improper Medical Necessity:

The true essence of a reimbursable claim is the right justification of “medical necessity”. In order to collect your reward for your hard-earned services, practitioners should mention accurate information about the reason behind the medical treatment delivered.

If your claim doesn’t contain clear-cut information about it then would definitely end up in the form of denial. So always make an informed decision before preparing and submitting claims to the insurance companies.

Such a claim that doesn’t contain justifiable information about the medical service causes two scenarios;

  • It may reinforce the physician to bear the overall cost of the services delivered.
  • Or it may cause patients to pay the complete amount for the services they have received.

Both situations cause damage to the physician’s practice’s reputation. In order to stay away from such mistakes, it’s better to consult with professional medical billing and coding companies.

Since they have state-of-art medical billing solutions, so they can

create reimbursable claims for your practice.


Practitioners should closely monitor their medical billing system to attain financial stability for their practice. If they would not pay attention then it would increase the chance of claim denials. As a result, they would not be able to collect maximum reimbursements.

It will hit their bottom line negatively. But they can resolve this issue simply by partnering with well-experienced medical billing and coding companies. In this way, they can get access to cutting-edge medical billing solutions and generate more revenue with less stress.

Medcare MSO is the nation’s leading medical billing company that helps medical providers to optimize their revenue growth all across the United States. Give your practice a chance and request a free demo of efficient medical billing solutions.

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