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Why Many Medical Claims Are Rejected on First Submission

Why Many Medical Claims Are Rejected on First Submission

Rejected medical claims cost you time and money. However, medical claims processing doesn’t need to be so difficult.

Getting a medical claim approved on first submission will make life easier for everybody.

Most insurance companies know that if they deny a claim right away, the odds are that they will never have to pay it. These are for-profit businesses, after all.

So how do you make sure all of your I’s are dotted and your T’s crossed so that the insurance company can’t reject your claims?

In this article, we’ll explore why medical claims are typically rejected on first submission and what you can do to avoid this unnecessary headache.

1. Transcript Errors That Need to Be Corrected

Most medical claims are initially rejected because they have easily avoidable errors.

For instance, if a patient’s birth date is December 21, 1975, and it’s submitted as December 21, 1976, the claim will be instantly rejected.

Attention to detail is key in medical claims processing because any minor error can void the claim.

If you’re wondering why a claim has been rejected when everything you’ve submitted seems to be in line, the first thing to do is check for errors or typos.

Something as simple as spelling the name Jane Johnsen instead of Jan Johnson can be a stop-gap that will keep a claim from being approved.

2. The Claim Was Filed with a Provider That is Not in Network

This is one of the most common reasons that medical claims get denied.

Many employer’s health coverage providers are HMO’s (Health Maintenance Organizations) and require a patient to stay within the network to be covered.

When a patient goes outside of the network, they are working with providers that haven’t agreed to the payment terms the insurance company has laid out. These claims will be denied.

In addition to this, non-emergency care or care that is not deemed as necessary from a medical perspective can be denied or paid out at a lower than expected rate.

In these cases, the patient will be expected to cover the entirety of the bill or pay a larger amount than expected.

Make sure your patients stick to providers that are within their HMO’s network and only have procedures done that are deemed necessary by doctors. Otherwise, their medical claims will be denied.

3. Medical Claims Charges Aren’t Covered by the Policy

There’s no doubt that insurance coverage is a complicated subject. If medical claims were rejected, there is a good chance that they were not covered by the insurance policy to begin with.

This can be very frustrating because none of us enjoy pouring through page after page of insurance jargon. However, before a treatment or procedure is performed, patients always need to verify if it is covered by their policy.

This avoids unpleasant and expensive surprises down the road.

Explain it to a patient like this: is it better to know now that a procedure won’t be covered so you can financially plan for it? Or is it better to be slapped with a huge and unexpected bill months after the procedure is complete?

The answer is evident.

Teach patients to spend some time pouring through their policy so they know what is and isn’t covered.

If they have questions about any specifics, call the insurance company and get the answers they need.

4. Was the Medical Claim Filed in a Timely Matter?

Delaying on filing medical claims will get them rejected more times than not.

Insurance companies expect that a claim will be filed in a reasonable time frame from when care was provided. If the claim isn’t filed within the benefit year, it will be denied.

The best policy is to file all medical claims as soon as humanly possible after treatment. This will avoid potential headaches down the road.

5. There Was No Referral or Pre-Authorization

In many cases, insurance companies will not cover medical claims that are done without a referral or pre-authorization from a doctor.

Especially in cases involving MRI’s or CT scans, a doctor needs to request or refer these. If they do not, the medical claim could be denied.

If you’ve received a denial for a procedure and are unclear why, find out if the doctor properly referred it. If it wasn’t, their office should be able to clear up the error.

6. Billing Error: The Medical Claims Went to the Wrong Insurance Company

This may sound ridiculous, but it happens quite often.

With millions upon millions of medical claims being processed every year, it’s easy for a claim to get directed into the wrong insurance company’s hands.

A common reason this happens is when a patient hasn’t seen a particular doctor for a long period of time. Often, the doctor will have out-dated information on file and will use that information for filing medical claims.

This is a sure-fire way for a medical claim to get denied.

Fortunately, you can streamline medical claims billing to avoid these common errors from happening.

7. Duplicate Coverage 

Expanding upon point number 6 is a scenario where a patient has duplicate coverage.

Some patients have coverage through their own employer as well as their spouse’s employer.

In this situation, it is common that medical claims get presented to the wrong insurance company and end up denied.

Duplicate coverage can be a great thing to help cover gaps in policy coverage. However, it can cause confusion in medical claims processing.

Make sure all claims are going to the right provider based upon the care provided. Missing this detail will get claims rejected on first submission every time.


Even if a medical claim is rejected on the first submission, it doesn’t mean that it’s time to give up.

Hospitals, doctors and health insurance companies can help reverse the rejection.

Stay on top of all medical claims from beginning to end. It is the insurance company’s job to pay out all claims that are within their contracted agreements.

If the claim is rejected on first submission, review these seven reasons why this may have happened. Then take action immediately.

To file medical claims faster and more effectively, and to focus more on patient care and less on insurance claims processing, join the thousands of providers across America using Apex EDI.



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How Technology Improved Medical Claims Auditing

How Technology Improved Medical Claims Auditing

When it comes to technology, perhaps no industry has been so helped by the advent as the healthcare industry

In particular, the claims audit process has evolved leaps and bounds with the development of software for the job.

Processing various claims by hand is tedious, painstaking, and frankly, takes too much time out of your day. In the healthcare industry, there are more things to worry about than audits – but how can you when they take up most of your time?

With the right software, you’ll be on your way to rearranging your priorities while still maintaining the accuracy that’s crucial to your job. 

Let’s take a look at how technology has helped shape the claims audit revolution and the amazing things it’s done for the industry.


The most obvious way in which technology has enhanced the claims audit process is by making it much more efficient. This one’s something of a no-brainer; a quicker, more accurate way of doing things will naturally lead to more efficiency.

Prior to the advent of technology, the billing and claims audit process was slow and tedious. With technology, things run much faster as we can process these requests in large batches.

Additionally, the software used gives us the chance to find any errors quickly. There’s no reason to do any of this by hand, though it’s always good to lend another set of eyes to a digitally-processed document.


The claims audit process had limited security in the past. With most of the work being done by hand, employees had access to personal information and financial contacts. 

While the risk of fraud was relatively low, the fact that the risk still existed was something of a turn-off – especially as physical copies of bills and claims were being stored.

Technology allows these items to be stored in the cloud. That means there’s no physical record on hand and no saved copy on someone’s personal computer. Everything is able to be stored electronically, and only those who needs access to the information have it.

The cloud is password protected, meaning that matters of security have become much less of a worry. Storing claims and bills is a much less risky process.


Sometimes, when things are done by hand, it’s possible for us to overlook errors multiple times. This can cause discrepancies between what we see and what the patient sees. 

However, while humans can be prone to error, computers typically aren’t. Most claims audit software both allows auditors to double- and triple-check their work and will bring attention to any glaring errors.

This means that there are fewer mistakes made, and those which are made are caught and fixed with ease. This means that there’s less chance of a claim being rejected, as the mistakes are typically caught before the claim is finalized.

This all ties right back into efficiency. With accuracy picking up, companies and auditors now have much more time to focus on other priorities.


The number of claims that need to be processed isn’t dwindling. Think about a number of claims received today, then think about processing the same number a couple decades back.

It’s a terrifying thought, isn’t it? You can almost see the physical mountain of claims stacking up. The thought of handpicking which claims to audit is even more daunting.

However, with the current software, it’s much easier. The process and task are still complex and require precision, but we can process claims much faster now. 

The claims with the highest error probability are traditionally the ones chosen for a claims audit, and with the speediness of the current process, we’re able to assess which ones are appropriate to audit instead of wasting time on trivial matters.

It can also provide you with data regarding how your organization is faring.


While there are some standard processes in the healthcare industry, each company is going to approach different processes with their own unique flair.

The advent of technology allows healthcare organizations to take whatever approach to claims audits that they wish. Regardless of how they choose to employ their own personal process, they can be certain that the software chosen will do its job properly.

This allows healthcare organizes an unparalleled level of freedom when it comes to conducting audits. 

It also allows managers to track the process every step of the way by providing a centralized dashboard. This means that anybody with the proper login credentials can watch an audit through every step.


When processing an audit by hand, it’s sometimes difficult to notice whether or not there’s an issue with any documentation or billing until you’ve already put in a vast amount of time into the project.

The great thing about technology for claims audits is that it takes this risk out of the equation entirely. The technology is so efficient that it’s capable of catching errors before even the most thorough human eyes.

Depending on the software used, it may even be able to resolve these errors without disregarding the work you’ve already put into it. Most software will even give each issue a new ID number. This means that managers or anybody involved can track each issue through the steps in the process.

Technology’s changed the claims audit climate

Technology has changed everyone’s lives in ways previously thought impossible. Ask anyone whether or not they expected to be holding miniature computers up to their ears as phones, and surprise will make itself apparent very quickly.

It’s important for all aspects of the medical industry to remain on top of technological developments. The further technology develops, the more lives can be saved.

As for the technical side of things, technology has allowed us to focus on different priorities for different organizations. Meanwhile, we haven’t had to make any sacrifices to accuracy.

If anything, technology has made us more accurate and ensured that we’re only auditing claims that hold water.

If you have any questions regarding the use of technology and software for claims audits, please don’t hesitate to contact us.

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Medical Claims: What Does the Medical Claims Process Look Like?

The medical claims process begins when the patient goes to the healthcare provider for any service, from refilling a prescription to major surgery. The patient is responsible for paying the insurance deductible after the visit and providing insurance information to the healthcare provider.

Health insurance claim form with glasses

Typically, front office staff begin the claims process with a pre-registration form. Information such as patient name, birth date, and insurance policy number is gathered. Keeping current medical records helps expedite the billing and patient check in process. It can also eliminate errors that may occur. For example, if the patient forgets to bring insurance information with them.

Once the patient provides insurance information, the office must confirm the medical services that are covered under the patient’s insurance policy and what medical conditions the insurance provider requires in order to justify financial payment.

When the patient receives service, it is important for the provider to record all medical services received. To bill the insurance company, each service must be coded accurately. The bill must also be compliant with legal requirements set forth in the Health Insurance Portability and Accountability Act (HIPAA).

It’s imperative to confirm that fees are charged accurately and that every code submitted is billable before it is sent to the insurance company. This insurance medical claim provides the payer with important information about the diagnosis, procedures, and the charges. An accurate insurance claim ensures that you are reimbursed in a timely manner.  

Apex EDI acts as a clearinghouse and liaison between healthcare providers and insurers. We can help format claims and submit the medical claim to the insurance company. Accurate, timely claims help you get paid faster. Interested in our help? Contact us, at Apex EDI, to watch a free demonstration of our medical claims software today.

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Medical Claims: Will Medical Claims Software Help My Practice? What Should I Look For?

Concentrated female doctor using computer at desk in medical office

Implementing a medical claims software is an easy way to see an immediate increase in revenue for your health care practice with a minimal investment. The software allows your staff to focus their time on what’s really important, the care of patients, rather than tracking and submitting medical claims. There are a number of features to look for in a good medical claims software.

First, you will want to make sure the software partner you select offers the best customer support possible. Look for a company that can offer the assistance of a well-trained, knowledgeable support staff to address any technology questions your staff may have. At Apex EDI, we are committed to providing the fastest, most personal, and most capable customer service and technical support in the electronic claims processing industry.

Then you will want to be certain the software is equipped to keep up with ongoing changes in the healthcare industry. The system must have the highest level of data security to remain in compliance with patient privacy regulations. You will also want superior coding and reporting functions that will increase the efficiency of your practice.

The American Medical Association reported that the average practice can cut medical claim submission costs by up to 55% by simply making the transition to an automated medical claims software. At Apex EDI, we want to help you reduce your costs and increase the accuracy of your claim submissions. Our medical claims software offers the most complete range of features in the industry. Contact us to watch a free demonstration of our software today.

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Medical Claims: What Can Medical Claims Software Do for My Clinic?

Computer system health or auditing - Stethoscope over a computer keyboard toned in blue

There are many benefits of having an up-to-date medical claims software tool. A good claims software system will help ensure you receive fast reimbursement for all the services you provide to your patients, stay compliant with current health regulations, save time and reduce costs for your office.

You will have instant access to all billing data and be able to monitor the performance of your practice using real-time financial information and analytics. The operational efficiency of your office can improve greatly by relying on a highly trained, supportive medical claims software team to respond to any questions you have about patient billing issues.

Electronic patient medical billing ensures your patient healthcare data is stored securely and in compliance with HIPPA (Health Insurance Portability and Accountability Act) regulations. This reduces the risk of a legal complaint for your office. You can also feel confident knowing you won’t have to shoulder the responsibility of any changes to billing regulations, unforeseen technical difficulties or data storage issues.

You have enough to focus on with patient registration, scheduling and providing quality health care for your patients. Let a trained and qualified medical claims software team take care of routine medical billing, billing related compliance, and the resolution of billing issues for you.

There is no easier way to have a direct impact on your clinic’s financial performance than a software tool that will ensure that you are paid promptly for the patient care you provide. Contact Apex EDI to request more information. We would love to provide you a free demonstration of our software today.

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