Let’s follow a claim that never made it to reimbursement. It started like every other standard service, expected coverage, nothing unusually complex. But somewhere between patient intake and payer response, things went sideways.
The result? A denial.
This isn’t an isolated case. Denials now affect nearly one in five in-network claims, and cost health systems billions in lost or delayed revenue. And while the final denial may show up as a simple code or reason on a report, the real story begins much earlier and involves more steps (and missed opportunities) than many teams realize.
Here’s how a denied claim takes shape and where things often go wrong.
Before the patient arrives
The claim’s trouble began before the patient even stepped foot in the door.
At scheduling, the patient’s insurance eligibility was never confirmed in real time. No flags were raised about an authorization requirement for the ordered procedure. And because front-end tools weren’t integrated into the scheduling system, no one noticed the policy had recently changed.
These kinds of errors are all too common. Eligibility and authorization-related issues remain among the top denial triggers, and they’re typically preventable. Without automated pre-checks, staff have to rely on manual workarounds or incomplete information, especially under pressure to keep schedules full.
And once that patient arrives and the service is rendered, it’s already too late to fix those missed steps.
At the front desk
As the patient checked in, a few more cracks started to show. The demographic data in the system was outdated—an old address, a name that no longer matched the insurance card, and a group number from a previous employer plan.
Staff were juggling multiple tasks, and without a system that validated inputs or flagged inconsistencies in real time, the incorrect information made it through. These small errors would later result in the payer flagging the claim as unmatched or incomplete.
Here’s the deeper issue: many health systems still treat registration as purely administrative, not as a critical phase of the revenue cycle. But errors at this step ripple forward. Denials triggered by incorrect patient information are entirely avoidable when the right checks and balances are in place.
After the visit
Once care was delivered, the documentation and coding process kicked in. But our claim’s problems didn’t stop there.
The procedure was coded correctly, but the coder didn’t have access to all supporting notes, so key supply usage wasn’t included. There was also no flag for a payer-specific modifier that should’ve been attached. The result was an incomplete, under-documented claim.
Scenarios like this are especially common in settings like ASCs or labs, where quick turnaround and high case volume can lead to missed details. When clinical documentation isn’t tightly integrated with coding workflows, and when coders are working off partial or unclear information, denials aren’t just possible, they’re predictable.
Technology could have helped. Systems that auto-populate codes based on physician documentation or flag missing data can dramatically reduce post-service errors. But without those tools (or if they’re underused), claims like this one go out the door unprepared.
Before submission
The claim was scrubbed, but not deeply. The clearinghouse caught basic format errors, but no one had embedded custom scrubbing rules based on recent denial patterns. There was no check for a missing modifier and no alert for the payer-specific policy that required additional documentation.
This is where many denials could be prevented with smarter pre-submission logic. Instead, the claim was sent, looking complete on the surface, but with issues baked in.
Scrubbing technology isn’t just about finding typos. It’s about preventing known patterns of failure. Without robust scrub logic that learns from past denials, organizations are repeatedly sending out claims with the same mistakes.
After submission
The claim reached the payer, but the problems quickly became apparent. The mismatch between the patient’s demographic info and their plan caused an initial rejection. The missing modifier triggered a technical denial. And the lack of documentation led the payer to flag the claim for medical necessity review.
Because the team lacked real-time claims status visibility, no one noticed the denial until it showed up in a weekly report. By then, the appeal window for one of the rejections had already closed.
When the denial finally landed on someone’s desk, it didn’t come with clear instructions for follow-up. There was no centralized appeals process, no prioritization logic, and no automation in place to generate responses. With higher-priority work already in the queue, this claim went untouched for weeks, then was written off.
Multiply that by dozens, even hundreds of claims, and the lost revenue adds up quickly.
What this claim teaches us
This claim didn’t fail because of a single glaring error. It slipped through the cracks because of a series of small, overlooked missteps across disconnected workflows.
Eligibility checks were missed early on, and outdated registration data went unnoticed. Incomplete documentation limited what could be coded and billed, while scrubbing processes failed to catch known payer requirements. By the time the denial landed, there was no clear follow-up process in place to recover what was owed.
Unfortunately, this is the rule, not the exception. Nearly half of providers still manage denials manually. Most lack the real-time visibility to see where claims break down. And few have fully adopted the automation and AI tools that can help prevent denials before they start.
The good news? Denials leave a trail. When teams know where to look—and have the RCM tools to intervene—claims like this one don’t have to be lost revenue.
Curious how your denied claims strategy stacks up?
Our opportunity assessment helps identify where gaps exist, what’s working, and what improvements can make the biggest impact, whether it’s front-end data capture, documentation quality, or downstream denial resolution.
Request your assessment today and take the first step toward smarter, more sustainable denial prevention.
