The Top Three Claim Denials to Work And How to Get Ahead of Them
Author: Tara Chmaissani, RCM Services
Claim denials represent one of the most significant barriers to steady cash flow in healthcare organizations. They increase administrative costs, delay reimbursements, and often require staff to spend time on tasks that could otherwise be avoided. According to industry benchmarks, nearly 10% of claims are initially denied, yet research shows that two-thirds of denials are preventable. Not all denials carry the same weight: some are highly complex, involving medical necessity, coding specificity, or lengthy payer appeals processes. Others, however, are much simpler to resolve and, more importantly, to prevent.
Understanding which denials fall into the “easiest to work” category can help organizations streamline their revenue cycle processes, prioritize resources, and reduce unnecessary write-offs. This article highlights the top three easiest denials to work:eligibility and coverage, coordination of benefits (COB), and authorization/referral denials,and provides strategies for proactively addressing them before they disrupt reimbursement.
Eligibility and Coverage Denials
Why They Occur
Eligibility and coverage denials are among the most common denials across all payer types. They typically arise when a patient’s insurance coverage is inactive on the date of service, when policy information is entered incorrectly, or when eligibility was never verified prior to the appointment. Because these denials stem from administrative oversights rather than complex coding or medical issues, they are usually straightforward to address.
Why They Are Easy to Work
Most eligibility denials can be resolved by updating or correcting insurance information and resubmitting the claim. In cases where the patient does have active coverage, staff can quickly verify benefits through payer portals or clearinghouses. If the patient truly lacks coverage, the denial can be converted into a self-pay balance and communicated accordingly.
How to Get Ahead of Them
- Implement automated, real-time eligibility checks. Eligibility verification tools should be used at scheduling, pre-registration, and check-in to reduce the chance of denials caused by outdated or inaccurate information.
- Standardize front-end workflows. Staff should always confirm key details such as patient name, date of birth, and policy number. Even small typographical errors can trigger eligibility rejections.
- Confirm secondary coverage. Many denials occur when patients fail to provide information on additional insurance policies. Routine prompts and scripted questions can ensure that coverage is captured in full.
- Train and empower front-line staff. Registration and scheduling teams serve as the first line of defense against eligibility denials. Ongoing training ensures consistency in capturing accurate information.
By prioritizing eligibility verification processes, organizations can reduce one of the most frequent and preventable denial categories, ultimately accelerating reimbursement and improving patient satisfaction.
Coordination of Benefits (COB) Denials
Why They Occur
Coordination of Benefits denials occur when a patient has more than one insurance policy and the payer requires clarification on which plan is primary. If the payer does not have current information about coverage order, claims may be denied until the patient provides updated details. These denials are particularly common with patients who have Medicare and supplemental plans, or with pediatric patients covered under multiple parental policies.
Why They Are Easy to Work
COB denials are administrative in nature. Once the patient or provider supplies the correct order of benefits, the payer reprocesses the claim without further issue. Unlike denials related to clinical criteria or documentation, COB denials generally require no coding review or medical record submission.
How to Get Ahead of Them
- Verify COB status annually and at each visit. Patients should be asked at registration whether they have multiple policies, and staff should verify whether a change in coverage has occurred.
- Educate patients on payer outreach. Insurance companies often send letters or calls to confirm coverage order. Patients should be reminded of the importance of responding promptly to avoid delayed claims.
- Leverage system flags and alerts. If a patient has a history of COB-related denials, the EHR or practice management system should flag the account so staff can proactively confirm information.
- Create escalation protocols. For recurring COB issues, assign a team member to follow up directly with the payer or patient before the claim is submitted.
When addressed proactively, COB denials can be almost entirely avoided, ensuring that claims are routed correctly on the first submission.
Authorization and Referral Denials
Why They Occur
Authorization and referral denials arise when required pre-approvals or referrals are not obtained prior to services being rendered. This denial type is common for imaging, surgeries, and specialty care. While these denials may seem more complicated, they are often among the easiest to overturn, particularly when the service was approved but the documentation was not properly linked to the claim.
Why They Are Easy to Work
In many cases, the authorization does exist but was not transmitted correctly, attached to the wrong claim, or omitted at submission. When staff provide the missing authorization number or supporting documentation, the payer typically reprocesses the claim. Even when authorization was overlooked, some payers will retroactively approve if the service was emergent or medically necessary, reducing revenue risk.
How to Get Ahead of Them
- Develop payer-specific checklists. Each payer has unique requirements for authorizations. Maintaining an updated reference by payer and service type ensures that staff know exactly when approvals are needed.
- Integrate system alerts. Scheduling and order-entry systems should be configured to flag services that require pre-authorization, reducing the chance of missed approvals.
- Centralize authorization tracking. Housing all authorization requests and approvals in a centralized repository allows for quick retrieval and reduces the likelihood of missed documentation.
- Educate clinical and scheduling teams. Providers and schedulers must understand the financial impact of skipped authorizations and work collaboratively with administrative staff to ensure compliance.
By implementing structured processes and leveraging technology, organizations can minimize authorization-related denials and quickly resolve those that occur.
How Healthrise Can Help
Preventing eligibility, coordination of benefits, and authorization-related denials requires strong front-end workflows, clear accountability, and the right use of technology. Healthrise helps organizations address these denial types at the source, before they disrupt reimbursement.
Healthrise partners with healthcare organizations to align people, processes, and EHR workflows across the revenue cycle, reducing avoidable rework and improving first-pass claim accuracy.
Our approach includes:
- Front-End Workflow Alignment.Standardizing registration, scheduling, and referral processes to ensure eligibility, COB, and authorization requirements are consistently verified prior to service.
- EHR Optimization and Automation.Configuring system alerts, flags, and rules that identify coverage, COB, and authorization risks early in the patient access and scheduling process.
- Denials Insight and Root-Cause Analysis.Analyzing denial patterns by payer and service line to identify recurring administrative gaps and prioritize high-impact corrective actions.
- Operational Support and Governance.Reinforcing best practices through coaching, education, and governance models that sustain performance over time.
By shifting focus from reactive denial work to proactive prevention, Healthrise helps organizations protect revenue, reduce administrative burden, and improve the patient financial experience.
Conclusion
While claim denials are an unavoidable reality in healthcare revenue cycle management, not all denials require significant time and resources to resolve. Eligibility and coverage, coordination of benefits, and authorization/referral denials are among the easiest to work because they are largely administrative in nature. They typically do not question the medical necessity or appropriateness of care but instead highlight gaps in front-end processes or documentation.
By strengthening eligibility verification, COB workflows, and authorization tracking, healthcare organizations can significantly reduce preventable denials, accelerate reimbursements, and improve overall revenue integrity. These improvements also contribute to a better patient financial experience, as patients are less likely to face unexpected bills or delays.
Ultimately, getting ahead of these denials is less about reactive problem-solving and more about building strong, proactive processes. In doing so, organizations can shift focus away from chasing avoidable denials and toward optimizing performance across the revenue cycle.
To learn how Healthrise can help your organization proactively reduce preventable denials and strengthen revenue cycle performance, contact our experts to start the conversation.
