Medical Claims, Medical Billing

5 Main Reasons Your Claims Get Denied

The medical billing process is very complex and has many interlinking factors. The process starts with the patient’s first interaction with the hospital/healthcare facility reception and ends with the doctor getting paid for his service for the patient. Due to the involvement of many parties throughout the process, errors can arise at any point. These errors can be the reasons your claims get denied or cause problems within the claim process and can lead to the claims being denied.

For a doctor, these claim denials can be very frustrating because they have to take time out of their busy schedule to deal with the impending error within the claims process. Thus, doctors must be well aware of the claims filing and denial process so that they can work with the authorities and quickly identify the problem. They must also know some of the significant reasons behind their claims getting denied, about which we will talk today.

What does Denial mean in Medical Billing?

Denial in medical billing means a refusal by the insurance company or payment provider to pay the doctor for the service he has done for the patient. When these cases happen, the insurance company can leave the service provider responsible for bearing the full-service cost to their patients, which means that the doctor has done the process free of cost and will not be paid. Claim denials can happen for many reasons, but mostly due to faulty claim documents, incorrect info in the billing documentation, or some other faults within the claims process.

To avoid these denials, the doctors must ensure they are working closely with the in-house medical billing department and that the authorities concerned with filling the data are doing their job correctly. The doctors must also ensure that they are filling all the data correctly and that the medical codes and modifiers used are the right ones.

5 Main Reasons Why your Claims get Denied

5 Main Reasons Why your Claims get Denied

Here are five main reasons why your claims get denied at your healthcare facility:

1.    Not Filing the Claims on time

The doctors must submit every claim at a specific time. Each claim has a due date attached to it, and the doctor must make sure to file that claim within the data mentioned. Ignoring the due date or neglecting the claim until the date has passed results in the expiry of the claim. This expiry can mean several things. Sometimes, the healthcare facility has to pay for the claim at its own expense. At other times, the insurance companies can deny the claims, and the doctor might not get paid for his service.

Sometimes, it may happen that the doctor can’t get the claim submitted on time due to the service list being incomplete. Such incomplete service lists, also known as charge tickets, get ignored by the payment providers, and the reimbursement might not come through. Even when the doctor fills the charge ticket, he might risk getting paid for the claim as the filling date might have passed.

2.    Incorrect Insurance Info and Wrong Insurance IDs

The payment providers check each patient’s insurance information and ID and verify all necessary info before reimbursing the payment to the doctor. Sometimes, the patients might have old insurance IDs or outdated insurance info that does not tally with the data in the insurance company database. This results in discrepancies in the patient data and the charges can’t be properly added to the patient account. These discrepancies then result in the claim getting denied.

Some insurance companies still rely on manual entry of data into the insurance system. These manual fillings of data are prone to many errors and can have many issues regarding patient info. Untrained staff members are another reason for such errors. All of these factors are harmful to the doctor eventually as they can’t get their claim reimbursed. 

3.    Un-Covered Services

Medical bills made by the patient contain information about the diagnosis and treatment of the disease. The doctors have to provide their services according to the diagnosis they have made, and anything not related to the diagnosis is denied when the claims are filed. Sometimes, it may happen that the service provided by the doctor might not coincide with the diagnosis listed on the medical bill. This discrepancy will result in the service not getting listed, and the claim for the service will be denied.

This mistake can also arise due to negligence in conveying correct info to the medical staff in charge of the billing process. The doctor might have provided a service according to the diagnosis listed on his notes, but the diagnosis might not have been correctly conveyed to the medical billing staff. This again results in incorrect data being put into the medical bill, and the service might not get charged. Thus, the doctors must list the correct diagnosis and treatment information.

4.    Collected Reporting of Separate Services

Each service performed by the doctor has its unique code and modifier. Since the doctors are paid based on these codes and modifiers, each service must be listed separately in the final medical bill. When some services are listed together, and no distinction is made between their codes, they might get counted as a single service. The claims for different services might then get mixed up, and the reimbursement can be accordingly decreased. The claim can also get altogether denied due to faulty info.

5.    Improper Code and Modifier Use

Codes and modifiers signify the service being done by the doctor for the treatment of the patient. As we have already discussed, these codes and modifiers are different for each service, and different services should not be mixed up together for the codes to work correctly. Sometimes, it may happen that the doctor himself or any other staff in charge of the billing process might not put the correct codes or modifiers within the billing documents. In these cases, the insurance provider can’t recognize if the doctor has done the service or not, and the claim might get denied.


Denials in the medical billing process are frustrating for the doctors and the payment providers. They waste the time of the payment companies as they have to figure out the errors and their solutions. Denials are especially frustrating for the doctors as their reimbursement, and, plainly speaking, their livelihood, is at stake. Many moving parts are involved in filing a claim, a fault in any of which might result in the claim getting denied. Not filing the claims within their due time, incorrect info, uncovered services done by the doctor, collective reporting of separate services, and improper use of codes and modifiers are some of the reasons behind the denials of claims. Doctors and the billing staff must make sure to input all data correctly and follow all the claim filing and submitting guidelines to the best of their knowledge to decrease the chances of getting the claims denied. Medical billing done right can sometimes make a huge difference for the doctor as he/she can get his /her due share of reimbursements and payments for the valuable services they offer to the patients.