Top 8 Claim Denials and How to Correct Them

Claim denials could mean a significant loss of revenue. If you face a claim denial, you can (and must) take action. Seasoned Medical Billing Services firms offer professional help to tackle the situation and maximize your revenues. Here are top reasons leading to denials and ways to get them right:

Eligibility criteria not met, or the coverage ended:

Insurance coverage depends on a variety of factors and may change over time. Verify the insurance eligibility every single time you offer your services to a patient. Be sure to check the insurance card of the patient when checking them in. You must critically review the insurance policy, the extent of coverage of the plan, and the policy expiry date. If the insurance plan expires (even recently), the claims could be denied leading to revenue leakage.

Top 8 Claim Denials and How to Correct Them

Missing information:

Any piece of information missing, even a single mandatory field left blank, could lead to denials. Review the claim critically to check for any empty fields and missing required documents.

Incorrect information:

Be sure that every piece of information you enter into the claim application form is correct and valid. Common erroneous fields include the patient’s name spelled wrongly, incorrect date of birth, wrong entry of medical plan number, insurance name with an error, and more. When the patient has multiple insurance covers, mention the primary one correctly to avoid confusion.

Problem with coding and modifiers:

Modifiers and the procedure codes play an important role. Every diagnosis needs to be coded accurately. Missing modifiers, an incorrect procedure code corresponding to the modifier could lead to denial of the claim. You must at all times use updated code-books like ICD-10 to avoid denials.

Untimely claim filing:

Insurance companies offer a limited span from the date of service within which you must file the claim. Filing the claims within the stipulated time frame is critical. If the claim is submitted after the deadline, the claim will be denied. If denied once, there is much less time to resubmit the claim. Even if you submit the claim before the end date but it is received after the end date, the claim will again be denied. The time frames differ with different insurance providers the safest would be to submit the claims without any delays. A professional medical billing services firm can cover you for accurate and timely billing.

Absence of prior authorization:

Pre-authorization (or prior authorization) is the process of getting approval from the insurance to determine coverage of services beforehand. Factors important to this approval are medical appropriateness, medical necessity, and benefit limits. The payer assigns an authorization number for the same that must be included in the final claim application. While this does not guarantee full reimbursement, it can surely minimize denials and is a safe option.

Incomplete documentation:

Claim applications must be supported with the necessary documents including the patient’s medical history, consultation reports and treatment summaries. Documents allow the payer to process based on the underlying rationale. Failing to offer the necessary documents could lead to claim denials.

The number of visits or services availed exceeds the permitted levels:

Many insurances permit only a stipulated number of visits or services to avail within a year. Be sure to check the eligibility with the insurance before offering the services to avoid denials.

Before appealing for a denied claim, you must find the reason(s) why the claim was denied, make necessary changes, and then resubmit the claim. Simply submitting the claim without making the necessary changes, can be considered as a duplicate claim submission and lead to denial again. A seasoned medical billing services company can help you quickly submit the claims with the necessary amendments.

Atlantic RCM is one of the leading multi-specialty medical billing companies in USA that serves 25+ major medical billing specialties. Our experts work across your practice in billing, collections and account receivables management, to help you succeed.

Get in touch with the leading medical billing outsourcing company to learn more. Call us at (469) 501-1500 or write to us Info@atlanticrcm.com