In 2024, 11.81% of medical claims were initially denied despite improved pre-auth processes. Insurers are denying more claims for medical necessity and requesting extra information, which slows down payments and adds work for your team. These denials aren't random. They follow predictable patterns rooted in specific documentation gaps that occur during pre-service operations. Understanding and eliminating these five critical gaps can significantly reduce your denial rates and protect your revenue stream.

Why Your Claims Still Get Denied

The five gaps fall into three critical stages where revenue leaks occur: patient intake, clinical capture, and coding alignment. By understanding where each gap strikes, you can implement targeted fixes. 

Registration & Demographic Errors

According to a 2023 national survey by HFMA and AKASA, errors in patient access and registration were the #1 cause of initial claim denials across hospitals and health systems. Failing to verify plan ID, group number, and primary insurance leads to claim rejections. 

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Start with scheduling templates that guide staff to collect patient information at the time of booking. Your team should verify this information within 24 to 48 hours of scheduling. HOM’s tech can integrate with your existing systems and adapt to your workflows.

Missed Eligibility and Authorization Checks

Once registration captures accurate patient data, the next vulnerability point emerges during benefit verification. The 2024 MGMA Stat poll shows that 60% of medical group leaders reported more claim denials than in 2023, which is why you should check each patient’s insurance and benefits before they arrive. 

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Use real-time eligibility checks within your current system. Standardized SOPs and checklists help your front desk team stay consistent. HOM helps you create custom workflows tailored to your specific practice needs. If you manage multiple locations or see high patient volumes, set up automated checks and alerts in your PMS. 

Clinical Documentation Gaps

Even with perfect registration and eligibility checks, revenue loss continues if clinical documentation fails to support the services provided. CMS made $31.46 billion in improper payments in 2022, and 63.6% of those were due to insufficient documentation. Every note needs to clearly connect the diagnosis, treatment plan, and expected outcome. 

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Documentation tools can flag incomplete fields and missing justifications. Clinical scribes and CDI experts make a huge difference here to capture billable data correctly. Regular internal audits spot these patterns before they become a problem.  HOM can assist you in making your notes more accurate, keeping you MRA-compliant, and getting your deserved payments.

Missed Authorizations and Referral Slip-Ups

Strong clinical notes mean nothing if required authorizations are missing from the equation. Front desk teams often struggle with the Coordination of Benefits (COB). Skipping a referral or a COB error can delay payments by months, leading to costly appeals and lost revenue. 

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Set up automated alerts that flag missing approvals in real time. Create custom escalation protocols that notify your team when prior authorizations are overdue or denied. Updating the Coordination of Benefits information during registration helps avoid post-visit billing surprises. HOM’s prior auth workflow includes automated checks, so you can spot missing approval before they delay payments. 

Mismatch Between Notes and Codes

The final gap occurs when otherwise solid clinical work gets undermined by coding mismatches. CMS reported that in 2024, 79% of Medicaid improper payments weren’t due to fraud, but simply due to incomplete documentation. That includes unsigned notes, vague procedure details, and missing attachments.

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Use coding audits to compare submitted CPTs against actual notes. Create clear, speciality-specific documentation checklists so providers know exactly what details to include for each code. This ensures every note supports the billed service.

Final Note

Documentation errors slow you down and quietly drain your revenue. We’ve seen missed diagnoses, uncaptured codes, and tiny gaps snowball into millions of dollars in lost reimbursements.

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In fact, when we worked with a large physician group in Florida, a thorough review of just 13,000 charts uncovered 1,110 missed diagnoses and over 2,200 retro-billing opportunities. 

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By tightening their documentation processes, the group saw a clear jump in reimbursements without adding new technology or disrupting workflows.

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If you’re following coding rules but still losing revenue, the problem might be hiding in plain sight. Let HOM’s expert team take a closer look. We’ll identify gaps, strengthen your workflows, and recover missed revenue. 

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Schedule your free revenue cycle assessment today to uncover documentation gaps that could be costing your practice thousands every month.