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Medical Claims Being Denied?

If yes, you've come to the right place! We'll go over some of the common reasons claims are denied and what we can do to help prevent denials.

Claim denials are costly and can decrease a practice's revenue. Let's take a look at the financial impact. There are several things we can control to prevent claim denials.

Prior Authorizations

aka precertification or prior approval

Per the American Medical Association, "Prior authorization—sometimes called precertification or prior approval—is a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage."

Different services require prior authorizations. These include:

* Medications

* Tests to be performed (CT Scans, MRI's, PET Scans, DMEs-Durable Medical Equipment)

* Needing to see a provider in a specialty:

-Physical Therapy

-Behavioral Health

-Pain / Medication Management



-and many more....

Ensuring the prior authorization has been provided and authorized is of great importance not only for billing purposes, but for the patient. It doesn't take long to call the insurance company of the patient to verify eligibility for the services being requested. I remember making a surgical consult appointment for myself and once I arrived at my appointment, I was told the prior authorization was not received. I couldn't believe the provider's office did not call to verify the prior authorization was not in. There's no need to put the patient through more stressful, time consuming issues when it can be handled with a simple phone call to verify information.

Claim Form Errors

Claim form errors are another huge issue causing claims to be denied. This is also a pet peeve of mine, because it's usually due to human error.

5 of the most common errors made of claim forms:

* Incorrect Medical Coding

-Not using the correct ICD-10, CPT, E/M, HCPCS

-Not using the correct modifier

-Upcoding and Down Coding

* Incorrect Provider and/ or Provider Numbers

-Know the difference between Rendering Provider (the provider that is rendering the services to the patient) and Referring Provider (the provider that is referring the patient to the rendering provider).


-Tax ID

* Incorrect Patient Demographics / Identifier

-Incorrect SSN

-Incorrect Insurance Number

-Incorrect Spelling of Patients Name

-Know the difference between subscriber (the person the insurance is carried under) and dependent (the person eligible to receive benefits / services under the subscriber's insurance policy usually spouse, parent, grandparent, or custodian if a minor)

*Claims submitted after the filing time

-Insurances have a timely filing period that ranges from 180 days to 1 year. It's up to you to know these deadlines

*Data Entry

-A simple slip of the finger can cause the whole claim to be denied. This is why it's imperative to check and double check spelling BEFORE submitting the claim for payment.

Please know the difference between these two forms:

This is the CMS 1500 form.

This is the claim form used by non-institutional (not a hospital) provider to bill for services or supplies (DME's) rendered.

You can use the form to submit the claim in paper form or electronic form.

This is the UB-04 form.

This is the claim form used by institutional (hospital, skilled nursing facilities, home health agency, hospice, certain laboratories, etc).

You can use the form to submit the claim in paper form or electric form.

Out of Network Providers

It's not only the duty of the patient to know whether their provider is in network or not, but it's also on the provider's office to know. The patient is most likely not in the healthcare field, so how can we expect for them to know if the services are in or out of network?!

Due diligence of the provider's office is important! An example: you have scheduled 40 new patients to come to your healthcare office and all of the insurances will cover the patient's visit. You get that 41st patient and you just assume that insurance will also cover the patient. The patient comes to the appointment and everything goes wonderful and they are so appreciative of you. Well, a month later they receive a bill for $1,500. They call you and are angry for the charge and they don't understand why they are being billed. That's when you realize the insurance will not cover the patient because they are not in network with your provider. Guess what happens next? Because you did not due your due diligence, you may have to write off the service and now the provider or facility is out of $1,500 or more. Or you have the patient pay for that service, they realize you were in the wrong and decide to sue your office. So not only will your office be out of the $1,500 but will probably be charged more due to the error and not handling it properly.

Again, this is simple human error. I understand that mistakes will happen, but we can cut down those mistakes by verifying, double checking and most of all communication!

Incorrect Insurance Billing:

Know & Understand Coordination of Benefits

Knowing and understanding Coordination of Benefits (COB) is extremely important and is also a huge reason for medical claim denials.

What is COB and why is it important? According to the CMS (Centers for Medicare & Medicaid Services) "Coordination of benefits (COB) allows plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities (i.e., determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an individual is covered by more than one plan)."

I hope that I was able to answer any questions. The main thing I want people to learn is that, denied claims equals no payment received for services provided and that your creditability is lost when claims are denied over and over for the same reason. It only takes a moment to check, double check, ask questions and verify.


Until We Meet Again....

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