10 Common Reasons Claims Gets Denied and Rejected
(1) Incorrect demographic information (insurance ID , date of birth, even the gender!)
Always scan a copy of your patient's primary and secondary insurance card. Make sure to get a copy of their new card (if there is a change)
(2) Patient's non-coverage or terminated coverage at the time of service may also be the reason of denial. That is why, it is very important that you check on your patient's benefits and eligibility before seeing the patient (unfortunately, I have seen practices who does not check benefits and eligibility on their patients so they end up being not paid for the service they have rendered for the patient
(3) Coding Issues (requires 5th digit, outdated codes)--- be careful also with your secondary/additional codes! Claims may be denied even if the problem was just because of the secondary codes!Again as I previously pointed out with my other articles on tracking your claims, with this problem, discuss solving the coding error rather than how much you want to get reimbursed. Most of the insurance companies will help you with codes (in fairness!!) and they also inform you on outdated codes, or codes that requires a 5th digit. You can also clarify by asking them more information on their reimbursement and utilization guidelines
(4) Improper use of modifiers (be careful with bilateral procedures!, modifiers for professional and technical component, modifiers for multiple procedures, postoperative period, etc.)
(5) No precertification or preauthorization obtained. It is so hard to file an appeal when the claim or service was non-precertified. Avoid this from happening! So be careful with your Surgical Procedures, Therapy Services and DME Services.
(6) No referral on file. HMOs or the Managed Care normally requires a referral! (remember that!). Most Therapy Services would require a an order or script from the referring provider. Make sure the referring provider's NPI appears on Box 17 on your HCFA 1500 Claim Form
(7) The patient has other primary insurance, the patient turn out to be a Workman's Comp case or an MVA case. Call our office, we can give you an example of our template of benefits eligibility verification. Remember, WC/MVA cases services are normally always require Prior Auth so make sure you have the claim information, connect with the Adjustor and the Nurse Case Manager
(8) Claim requires documentation, require additional notes to support medical necessity. A well documented medical records is a good practice!
(9) Claim requires referring physician's information (very common for Therapy Services and DME Billing requirements)
(10) Untimely filing. So how can you prove that you did submit the claims in a timely manner? When unfortunately, most of the insurances does not accept your billing records on your practice management software that shows that date(s) you billed the insurance! They want a receipt from your electronic receipt or for postal mail, obviously they want a receipt too! a tracking number maybe? certified letter receipt? If you are submitting claims by electronic, make sure you generate transmission reports/receipts. Your reports must read "accepted" or "in process" and not "rejected". If you are sending claims by paper or postal mail, it is a good idea to send your claims as certified mail with tracking number, keep your transmission receipts!
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ABOUT THE AUTHOR:
Ms. Pinky Maniri-Pescasio is the Founder of GoHealthcare Consulting. She is a National Speaker on Practice Reimbursement and a Physician Advocate. She has served the Medical Practice Industry for more than 25 years as a Professional Consultant.