For years, healthcare organizations have treated denials primarily as a back-end revenue cycle problem. A claim is submitted, the payer denies it, and a team works the account until it’s corrected, appealed, written off, or paid.
That model is getting harder to sustain.
Margins are getting tighter. Reimbursement pressure continues to grow. Financial constraints leave little room for labor-intensive work.
Forty-one percent of providers reported denial rates of 10% or higher, according to Experian Health’s 2025 State of Claims survey. That’s up from 38% in 2024 and 30% in 2022. At the same time, 43% of respondents said they were understaffed, and 90% of denied claims still require at least some level of human review before resubmission.
From a revenue cycle perspective, the lesson is clear: organizations can’t simply work their way out of the denial problem.
The bigger opportunity is preventing denials before they happen with EHR-native guidance.
Our recent insight brief goes deeper into this topic:
Denial rates vary by payer, organization, and service line. Still, many organizations see the same denial categories repeatedly. The 10 items below represent some of the most common reasons for healthcare denials – and some of the best opportunities to reduce rework before it starts.
1. Prior authorization denials
Prior authorization remains one of the most persistent revenue cycle challenges. Experian identified authorization as the second-leading denial category in 2025, cited by 35% of providers.
But getting authorization isn’t enough.
The authorization has to match what was ultimately performed, including procedure codes, units, dates of service, the rendering provider, and the site of care.
Moreover, treatment plans change. When the service performed differs from what was originally authorized, organizations need workflows that identify the discrepancy before a claim is submitted. For example, the CPT® code for surgical removal of the uterus is weight-based, yet the weight of a uterus isn’t known in advance of the procedure.
And the impact goes beyond reimbursement. Forty-one percent of people who experienced a prior authorization denial reported a delay in medical care, according to the Commonwealth Fund’s 2025 Affordability Survey. Another 28% said a health problem worsened as a result.
For more on prior authorization, register for our expert-led webinar, taking place November 5, 2026:
2. Medical necessity denials
Medical necessity denials may account for a smaller share of total denials, but frequency alone doesn’t tell the full story.
These denials often involve high-dollar services and require significant clinical expertise to resolve.
Requirements may come from Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), or commercial payer medical policies. Preventing these denials means linking the ordered service, diagnosis, documentation, and applicable coverage criteria before delivering care.
A clean claim can still be denied if the underlying clinical requirements for coverage aren’t met.
3. Coding denials
Coding-related denials encompass far more than choosing the wrong CPT or ICD-10-CM code.
Modifiers, diagnosis-to-procedure relationships, Excludes1 rules, bundling rules, specificity requirements, and payer-specific coding policies can all come into play. In fact, Experian’s survey found that 24% of providers cited coding inaccuracies as a leading denial trigger.
Coding also affects authorization and medical necessity. The codes associated with an order may determine whether authorization is required, and which coverage criteria apply. If the billed code differs from the code reviewed upstream, even a successful authorization or medical necessity review may not prevent a denial.
When it comes to denials prevention, clinical data governance must also be addressed. Read about it here:
4. Eligibility and coverage denials
Eligibility verification seems straightforward – until it isn’t.
Coverage can terminate or change between scheduling and the date of service. Patients may have multiple insurance plans, and coverage may apply only to certain providers, locations, or services.
Eligibility therefore should not be viewed as a one-time administrative task. For services scheduled well in advance, organizations may need to verify coverage again closer to the date of service.
5. Noncovered or excluded services
Eligibility confirms whether a patient has active insurance, but it doesn’t necessarily confirm whether a specific service is covered.
KFF found that excluded services represented 14% of reported in-network denial reasons among HealthCare.gov plans.
Benefit exclusions, visit limitations, investigational or experimental policies, and plan-specific restrictions can all result in noncovered-service denials.
When these requirements are identified before care, organizations have more options. Just as important, they can communicate potential financial responsibility before the bill arrives.
6. Registration and demographic denials
Some of the most preventable denials begin with simple mistakes.
An incorrect member ID. A misspelled name. An inaccurate date of birth. Outdated insurance information. An incorrect subscriber relationship.
Experian found that incomplete or incorrect registration data was the third-leading reported denial trigger in 2025. The same report found that for 26% of providers, at least 10% of denials stemmed from inaccurate or incomplete information collected during patient intake.
These may show up as claim errors, but the root cause is usually upstream data quality.
7. Missing or insufficient documentation
Documentation denials can occur when required medical records aren’t submitted, orders or signatures are missing, or documentation doesn’t adequately support the services billed.
These denials are also among the hardest to correct.
Documentation created later can’t always recreate the clinical picture that existed when care was delivered. The strongest defense is documentation that supports the patient’s condition, explains the reason for the service, and reflects the care provided, not documentation assembled only after a payer requests it.
8. Timely filing denials
Few denials categories are more frustrating.
The claims may be covered and clinically appropriate, yet the filing deadline is missed.
Registration problems, coding reviews, claim edits, or incorrect payer information can all consume valuable filing time. Corrected claims and secondary billing often come with their own deadlines as well.
Monitoring claims that are approaching filing limits and addressing the bottlenecks that create delays can prevent otherwise collectible revenue from turning into contractual write-offs.
9. Duplicate claim denials
Some duplicate denials are legitimate. Others result from attempts to correct or resubmit previously processed claims.
Strong claim-status workflows can help reduce unnecessary resubmissions while ensuring corrected claims follow payer-specific requirements. Organizations should also look for recurring patterns instead of treating every duplicate denial as an isolated event.
10. Provider, network, and credentialing denials
A covered service can still be denied because of who performed it or where it was performed.
Out-of-network providers, enrollment or credentialing issues, incorrect billing/rendering provider information, and site-of-service restrictions can all jeopardize reimbursement.
These risks become especially important when organizations add clinicians, expand locations, or deliver services across multiple facilities. And payers can make errors, too. Watch for trends and potential erroneous denials.
Moving from denial management to denial prevention
Preventing denials requires addressing their root causes earlier in the clinical and revenue cycle workflow. IMO Health’s denial prevention solutions help address common denial drivers at the point of documentation and ordering, where intervention has the greatest impact.
IMO Coding Intelligence helps strengthen coding accuracy by identifying opportunities to improve diagnosis specificity, including the use of primary versus non-primary diagnoses and the reduction of unspecified codes when more clinically appropriate alternatives are available.
This allows organizations to address diagnosis specificity, sequencing, and documentation completeness while the clinical context is still fresh and the ordering provider is actively engaged.
At the same time, IMO Health’s medical necessity solution evaluates ordered services against commercial payer medical policies to help determine whether the clinical documentation and diagnosis support the requested service.
Potential medical necessity issues can therefore be addressed during the ordering workflow, rather than later in the authorization or claims process.
Learn more about EHR-native guidance here:
Together, these denials prevention solutions address two key root causes of denials: coding-related inaccuracies and insufficient demonstration of clinical appropriateness. By delivering guidance within existing clinical and revenue cycle workflows, organizations can address potential problems before they become denials.
After all, the best denial isn’t the one your team successfully appeals. It’s the one that never happens.
