Claim denial rate
The percentage of submitted claims that are rejected or denied by payers on first submission. A denied claim means the payer refused to pay, either because of missing information, coding errors, eligibility issues, or authorization failures.
Why this matters for your clinic
Every denied claim costs you twice: once in lost revenue and once in the staff time required to rework and resubmit it. MGMA and HFMA industry data commonly cite $25–$118 per reworked claim in staff time depending on complexity. Multiply that by hundreds of denials per month and it adds up fast.
The real problem with high denial rates is not the denials themselves. It is that most clinics do not track them by reason code. Without that data, you cannot fix the root cause. You just keep submitting bad claims and reworking them forever.
What good looks like
HFMA MAP Keys target initial denial rate below 5% of gross charges. The Change Healthcare Revenue Cycle Denials Index has reported average initial denial rates above 11% in recent editions, with eligibility and registration errors among the top root causes. AAPC guidance treats anything above 10% as a signal of systemic billing process issues. Track by reason code, not just the total percentage.
From Sorso
In the mental health practices we've audited, eligibility-related denials drive the majority of total denial volume — and they're the cheapest category to fix because they don't require a coder.
Founder of Sorso. 18 years in corporate finance. Managed a $450M loan portfolio before building a fractional CFO firm exclusively for healthcare clinics.
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