3 Common Culprits in Claims Rejections

Claim Rejected

Did you know that the average claims rejection rate is roughly 5 percent? This means 1 in 20 claims is rejected by Medicare. Recent data suggests that family practice groups have an average rejection rate of 5 to 10 percent. Do you know where your practice stands against the benchmark for your specialty?

Wherever your practice may fall within the rejection spectrum, you should know this: A healthy rejection rate does not mean you can be complacent. Every claim rejected is cash left on the table. Every claim denied has a direct impact on your profit margin.

If your rejection rate is off the charts, however, you need to do something about it now. Here are 3 of the most common culprits in claims rejection:


When it comes to avoiding rejected claims, timing is critical. Your practice could be making one of several timing errors, leading to a higher than normal rejection rate.

  •      Filing after the deadline (60-90 days) has passed
  •      Using an expired authorization or referral
  •      Providing services prior to authorization approval
  •      Exceeding the number of authorized services or visits

Example: Although well-trained and experienced, if your front office staff cannot keep up with the workload at your practice, a third-party vendor could be the solution. End-to-end integrated EMR services save valuable time by keeping patient information up-to-date, avoiding delays in filing claims, and ensuring full compliance with the latest regulations, thus boosting revenue.


Several (avoidable) registration errors can increase your rejection rate. Your front desk staff should ensure that they:

  •      Verify coverage and enrollment status before rendering services
  •      Update insurance information in the EHR so that claims are sent to the correct carrier
  •      Check requirements for in-network and out-of-network providers
  •      Obtain valid referrals and authorizations

Example:  CMS periodically proposes new rules and regulations for provider reimbursement. Some expenses incurred in the treatment of Medicare patients are difficult to file correctly. If your practice is struggling to keep all the required authorizations and referrals for each patient updated on file, you could benefit from expert help.


An inept billing department at your practice could be bleeding money without your even knowing it. Failure to meet coding requirements is by far the most frequent cause of delays and denials in reimbursement. Here are some of the most common trouble spots:

  •      Mismatching diagnostic and procedure codes
  •      Mismatching CPT and location codes
  •      Provision of services at an unregistered location

Example: If your claims are repeatedly denied due to billing and coding mistakes, invest in a refresher course for in-house billing staff or consider outsourcing to a third-party billing company with expertise in and access to correct procedures and information. Increasing your billing accuracy is one of the easiest ways to improve your reimbursement rate.

Contact us to find out how we can help get your claims paid.

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