How to reduce claim denials: 12 fixes that actually work

A denial is the payer telling you it will not pay a claim as submitted. Some denials are the payer being difficult. Most are not. They are the result of something that went wrong earlier in your own process, which means they can be prevented.

Preventing a denial is always cheaper than working one. A denied claim has to be researched, corrected or appealed, and followed up again. Many practices never get round to it, and those claims are simply lost.

First, measure where denials come from

Before fixing anything, group your denials from the last three months by reason code (the CARC on the remittance) and by payer. You will usually find that a handful of reasons cause most of your denials. Fix those first. If a code is unfamiliar, look it up in our denial code lookup.

The 12 fixes

1. Capture registration data carefully

Scan both sides of the insurance card at every visit, confirm the patient's name exactly as it appears on the card, and confirm the date of birth. Patient-data errors cause rejections that look small but add up.

2. Verify eligibility before every visit

Not once a year: before every visit. Coverage changes at job changes, renewals and turning 65. Check close to the date of service. Use this checklist.

3. Identify the right payer

Many plans send behavioral health, therapy, imaging or pharmacy to a separate company. A claim sent to the main plan instead of the carve-out will be denied.

4. Track authorizations as data, not paperwork

Record each authorization's number, approved units and dates, and check them before scheduling. Expired or exhausted authorizations are a top cause of denials in therapy and specialty care. More on prior authorization.

5. Confirm coordination of benefits

If a patient has two plans, the order matters. Ask at every visit whether there is other coverage and update the primary/secondary order when it changes.

6. Scrub claims before they go out

A claim scrubber checks for missing fields, invalid code combinations, missing modifiers and payer-specific rules before submission. Every error caught here is a denial that never happens.

7. Link diagnoses carefully

Each service line should point to the diagnosis that justifies it. A test or procedure linked to a diagnosis the payer does not accept for it is denied as not medically necessary.

8. Use modifiers correctly

Modifiers like 25, 59 and the X modifiers tell the payer that services billed together were separate. Missing them causes bundling denials; overusing them invites audits.

9. Submit on time

Every payer has a timely filing limit, and some are short. Submit daily and track claims close to their deadline. A timely filing denial is almost impossible to overturn.

10. Credential providers before they see patients

Claims for a provider who is not yet enrolled with a payer are denied. Hold those claims, or schedule the provider with payers they are enrolled with, until enrollment is effective.

11. Work every denial within days

Denials get harder to fix as they age. Route each one to an owner the day the remittance is posted, and decide quickly whether it needs a corrected claim or an appeal.

12. Close the loop

For every recurring denial, ask which step caused it and add a check at that step. This is the difference between working denials forever and making them stop.

Corrected claim or appeal?

If the claim was wrong, such as a code, a modifier or patient data, fix it and send a corrected claim. If the claim was right and the payer applied a rule incorrectly, appeal with documentation. Sending an appeal for a claim that simply had an error wastes weeks.

How GetMax helps

GetMax checks eligibility before visits, tracks authorizations, scrubs claims before submission and groups denials by root cause, with an AI agent that drafts appeals for your team to review. If you would rather hand the work over, our denial management service runs it for you.