Did you know that 65% of denied claims are never resubmitted? For a typical Miami medical practice, this represents hundreds of thousands of dollars in lost revenue every year. The good news: most denials are preventable, and even denied claims can often be successfully appealed with the right process.
The 5 Most Common Denial Types in Miami
1. Eligibility Denials
Patient was not eligible at time of service. This is the most common denial type and often preventable with proper front-end verification. Miami's diverse payer mix—including snowbird patients with seasonal coverage changes—makes eligibility verification especially critical.
2. Authorization/Prior Auth Denials
Service required prior authorization that was not obtained. Florida Medicaid and many managed care plans in South Florida have extensive prior authorization requirements. Without proper authorization documentation, the claim will be denied regardless of medical necessity.
3. Medical Necessity Denials
Payer determined the service was not medically necessary based on the documentation submitted. Florida has particularly active audit activity around medical necessity, especially for high-cost specialties like cardiology, orthopedics, and pain management.
4. Coding Denials
Incorrect or mismatched codes—ICD-10, CPT, or modifier errors. With over 75,000 ICD-10 codes and thousands of CPT codes, coding errors are common. Miami's high-volume practices especially struggle with modifier errors (-25, -59, -RT, -LT).
5. Timely Filing Denials
Claim was submitted after the payer's timely filing deadline. Commercial payers typically allow 90 days; Medicare allows 12 months. Practices overwhelmed with high claim volumes often miss these deadlines.
The MBMB Denial Management Process
We don't just resubmit denied claims—we analyze why the denial occurred and fix the root cause. Here's our 5-step process:
Denial Identification & Categorization
Every denied claim is logged within 24 hours and categorized by denial type to identify patterns.
Root Cause Analysis
We identify whether the denial stems from registration, coding, authorization, documentation, or timely filing issues.
Correct & Resubmit
Coding errors are corrected; missing authorizations are obtained; documentation is supplemented where possible.
Appeal When Necessary
If the denial is incorrect, we file a formal appeal with all supporting documentation within the appeal timeframe.
Prevention Implementation
Root cause analysis informs process changes to prevent future denials of the same type.
Ready to Reduce Your Denial Rate?
We help Miami practices reduce denials from 15-20% to under 5%. Schedule a free billing audit to see how much revenue you could be recovering.