Why Are My Medical Claims Being Denied? A Guide to Finding and Fixing the Root Cause

Fixing the Root Cause

If you feel like you’re spending more time fighting denied claims than actually getting paid, you’re not alone. Denials are one of the biggest drains on a practice’s revenue and staff morale. But constantly appealing individual claims is just putting a bandage on the problem. The real solution lies in digging deeper to find the root cause and fixing your process for good. Let’s walk through how to do it.

The Real Cost of a Denied Claim

It’s not just about the single lost payment. The real cost includes:
  • Staff Time: The hours your biller spends identifying, researching, and resubmitting the claim.
  • Cash Flow Delays: It can take weeks or even months to resolve a denial, straining your finances.
  • Administrative Burden: The mental energy spent on a frustrating, repetitive task.

How to Conduct a Simple Root Cause Analysis

You don’t need a complicated system. Start here:

Step 1: Categorize Your Denials

Don’t just look at them as “denials.” Sort them into buckets. Common categories include:
  • Eligibility & Registration: (e.g., Coverage terminated, Incorrect patient ID)
  • Authorization: (e.g., Pre-certification missing, Referral required)
  • Coding: (e.g., Invalid CPT code, Mismatched ICD-10)
  • Clerical: (e.g., Duplicate claim, Incorrect patient info)

Step 2: Identify Patterns

Is one payer denying for the same reason? Is one provider’s claims getting rejected more often? Is a specific code frequently problematic? Patterns point directly to the process flaw.

Step 3: Implement a Fix and Monitor

Once you find the pattern, you can fix it. For example:

  • Problem: Multiple denials for "lack of pre-authorization."
  • Root Cause: Front desk staff isn't consistently checking authorization requirements during scheduling.
  • Fix: Implement a mandatory insurance check protocol before confirming any appointment.

When It's Time to Call for Backup

Doing this analysis is time-consuming. If you’re overwhelmed or the denials keep piling up, it might be a sign to partner with experts who have the technology and experience to do it at scale.

Tired of Being a Detective? We Can Help.

At Patel RCM Analytics, we use AI-powered analytics to automatically categorize denials and pinpoint root causes for our clients. This allows us to stop problems before they start, often reducing denial rates by 40% or more. If you’re ready to stop firefighting and start preventing, speak with one of our specialists today.