Common Claim Denial Mistakes (and How to Fix Them)
Stop Losing Revenue and Patient Trust: Tackle Claim Denials Like a Healthcare Pro
Claim denials are a part of life. Every healthcare practice, hospital, and billing department dreads them. When a health insurance claim is declined, it slows down reimbursements, frustrates staff and patients, and erodes your organization’s bottom line. Worst of all, claims denials can lead to poor patient outcomes.
The good news? Many claim denials are preventable. In this article, we break down the most common claim denial mistakes, plus step-by-step fixes to boost your approval rates.
Why Claims Get Denied: The Usual Suspects
Claims denials occur for a number of reasons, with many trends occurring across various types of healthcare practices and clinics. Statistics from 2025 suggest that claims denials are on the rise, and at last count, around $262 billion in claims were denied per year. To break it down, those claims account for nearly a tenth of the $3 trillion in claims submitted.
Key reasons for claims being denied include:
Inaccurate or incomplete patient data: Failing to update electronic health records (EHRs) with correct patient data causes delays and drives 68% of denials.
Insufficient technology: 44% of healthcare professionals state that their digital claims tools don’t meet revenue cycle requirements.
Poor eligibility checks: Requesting excluded services or failing to provide prior authorization are also top reasons for claims denials.
Billing and coding errors: Up-coding and unbundling are examples of coding errors that result in denials because the procedure is unnecessarily expensive. Other coding errors include mismatched procedures and diagnoses.
Lack of supporting documentation: Notes and lab results are required for many claims to be successful. It’s also important to submit the required forms and documentation within the provided window.
Clearly, many of the issues are administrative or due to the change from disparate patient data systems to more cohesive systems.
How to Prevent Most Claim Denials
While some claim denials will always exist, you can improve your patient outcomes and provider reputation by focusing on issues that you can fix.
1. Prioritize Accurate and Complete Patient Data
Shifting from legacy systems or even paper records to EHR systems like NextGen tools can allow patient data to slip through the cracks. Consider partnering with experts to optimize the implementation and integration of new systems. Ensure every member of your team is trained on the new system and adopt processes for double-checking patient data prior to claims submissions.
Pro Tip: Use digital check-in kiosks to let patients review and update data on the spot.
2. Make Authorization Documentation a Priority
Missing authorization documentation and notes are the top causes of claims denials. Use your practice management tools to create workflows that prompt claims administrators to check for pre- and prior-auth documentation.
Pro Tip: A shared calendar or dashboard lets you send authorization documents to a clinician quickly, helping prevent delays.
3. Staff Training on Billing Codes
Regularly upskill your teams on billing codes to avoid costly errors, such as declines for the wrong treatment, diagnosis/procedure mismatches, or unbundled treatment plans.
Pro Tip: Review your last 100 denied claims to identify coding errors. You might find a quick fix to boost your approval rates.
The Importance of Appealing Denied Claims
According to recent figures, only 5% of claims are formally appealed. Reasons for failing to appeal include missing deadlines for processing the appeal, additional administrative time, and the expense of paying for these additional employee hours.
Tips for appeals:
Act quickly: Appeals windows vary between providers, so ensure your information is accurate.
Be specific: Address the exact denial reason, ensuring you refer to payer guidelines.
Follow payer protocols to the letter: Failure to do so inevitably leads to appeals being thrown out.
Document everything: Keep clear records of every contact, resubmission/appeal dates, and decisions. Proper documentation helps protect your practice in case of disputes.
Understanding the ROI of Denial Prevention
The return on investment (ROI) of focusing on reduced claims denials is larger than you might think. As well as ensuring boosted cash flow, you build patient trust, organically improving your organization’s reputation. You also improve patient outcomes, leading to healthier, happier patients who will return to use your services the next time they’re in need.
Administration personnel can work smarter, not harder, freeing up employee hours to spend on other tasks. By implementing effective claims workflows and processes, you can reduce staff stress and burnout across your organization.
Start Your Denial Reduction Journey Today with TempDev
You can start assessing the state of claims denials in your practice by looking for patterns and implementing one process improvement immediately. Optimize your EHR workflows and templates by working with TempDev, experts in NextGen EHR and EPM systems.
Contact us online or by calling us at 888.TEMPDEV to find out more about cutting your claims denials and boosting your bottom line.
Ready to get more of your NextGen system?
Help your organization achieve measurable improvements in efficiency, compliance, and performance.
