10 Common Reasons Why Medical Claims were being Denied and
your Action Plan
by: Ms. Pinky Mcbanon
Senior Medical Billing Specialist (Dansalan Group, Inc.)
your Action Plan
by: Ms. Pinky Mcbanon
Senior Medical Billing Specialist (Dansalan Group, Inc.)
(1) Incorrect patient’s information (insurance ID# , date of birth)
If you are submitting electronic claims, AVOID entering patient’s insurance
number with characters like an asterisk (*) and dash (-) in between the
alphanumeric numbers because these characters can be recognize by
electronic as unrecognizable.
Always make a copy of your patient's primary & secondary insurance card on
file (copy front and back!). 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 see the patient (unfortunately, I have seen practices who
does not check on benefits and eligibility on their patients so they end being
not paid for the service they rendered for the patient)
(3) CPT/ICD9 Coding Issues (requires 5th digit, outdated codes)---
be careful also with your secondary code! Claims may be denied even if the
problem was just because of the secondary CPT/ICD9 code!
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 and they also inform you on outdated codes, or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.
(4) Incorrect 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 (if required)
It is so hard to file an appeal when the claim or service was non-precertified.
Avoid it from happening!
(6) No referral on file (if required)
Note: HMOs always requires a referral! (remember that!)
(7) The patient has other primary insurance or the patient’s claim
is for workman’s comp or auto accident claim!
It is the responsibility of your front desk staff to get all the necessary
information before the patient can be seen.
Remember that if this is a workman’s comp or an auto accident claim, you
need a claim number and the adjustor’s
name. Services are always preauthorized!
(8) Claim requires documentation & notes to support medical
necessity
A well documented medical records is a good practice!
(9) Claim requires referring physician’s info (with UPIN ofcourse!-this
will be soon replaced by an NPI or the National Provider Identification number)
(10) Untimely filing
Unfortunately most of the insurances does not accept your billing records on
your office computer 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" and not
"rejected". File all these transmittal reports/ and receipts and a very safe
place!
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 receipts!!
If you are submitting electronic claims, AVOID entering patient’s insurance
number with characters like an asterisk (*) and dash (-) in between the
alphanumeric numbers because these characters can be recognize by
electronic as unrecognizable.
Always make a copy of your patient's primary & secondary insurance card on
file (copy front and back!). 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 see the patient (unfortunately, I have seen practices who
does not check on benefits and eligibility on their patients so they end being
not paid for the service they rendered for the patient)
(3) CPT/ICD9 Coding Issues (requires 5th digit, outdated codes)---
be careful also with your secondary code! Claims may be denied even if the
problem was just because of the secondary CPT/ICD9 code!
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.
(4) Incorrect 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 (if required)
It is so hard to file an appeal when the claim or service was non-precertified.
Avoid it from happening!
(6) No referral on file (if required)
Note: HMOs always requires a referral! (remember that!)
(7) The patient has other primary insurance or the patient’s claim
is for workman’s comp or auto accident claim!
It is the responsibility of your front desk staff to get all the necessary
information before the patient can be seen.
Remember that if this is a workman’s comp or an auto accident claim, you
need a claim number and the adjustor’s
name. Services are always preauthorized!
(8) Claim requires documentation & notes to support medical
necessity
A well documented medical records is a good practice!
(9) Claim requires referring physician’s info (with UPIN ofcourse!-this
will be soon replaced by an NPI or the National Provider Identification number)
(10) Untimely filing
Unfortunately most of the insurances does not accept your billing records on
your office computer 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" and not
"rejected". File all these transmittal reports/ and receipts and a very safe
place!
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 receipts!!
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| Dansalan Group, Inc. is your Medical Billing Solution for your Medical Practice Outsourcing your Medical Billing to us is COST EFFECTIVE and HIPAA Compliant. Contact Us Now. |
| We know how frustrating it is. We've heard a lot of doctors' problems about their medical billing and their slow cash flow. No matter how you do your best, it is just not working. Lack of qualified and experienced in-house billers, under-staff office and lack of office staff training are major issues. Outsourcing your Medical Billing might be a good option. Why not? It's cost effective and reliable. Let's do the Math. |
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