15 Reasons For Claim Denials and How To Prevent Them

Why Are Your Claims Getting Denied?

Claims get denied for a variety of reasons – some of them are extremely simple to remedied, while others may require entire shifts in your organizational structure. The question is, could any of them been prevented? Many claim denials are completely avoidable – and in fact there are practical ways you can combat claim denials. Look at the following common claim denial reasons and see if any of them have happened to you recently:

1. You didn’t receive reimbursement the first time a claim was submitted, so you’ve submitted again resulting in duplicate claims.

Strategy for prevention: Keep a log of all submitted claims and before you resubmit, make sure that you have, in record for the payer, proof of the date the original claim was submitted. If you resubmit and it results in a duplicate, the penalty’s on you, but if you can prove it was submitted, the ball’s in the payer’s court, and if they’ve lost it, they’re accountable.

2. The patient’s health care coverage ran out.

Strategy for prevention: Of course you should always know definitively what the patient’s coverage status is when they’re being treated, but sometimes, coverage status can change in an instant. Be sure to verify coverage at each point of service.

3. The patient has health insurance coverage but has not yet met their deductible for the current year.

Strategy for prevention: Keep patients informed and educated about how their deductible works in regards to their insurance. Patients should be at least peripherally aware of the reimbursement process for their physicians and healthcare providers.

4. You’re billing for bundled payments that can’t be billed for separately. Lab orders are commonly bundled payments (i.e. you can’t bill for each one separately, you must bundle them according to profile).

Strategy for prevention: Know what the protocol is around billing for bundled payments is in your organization as well as with each individual payer. Know when to bundle payments and when not to. An easy way to avoid denials!

5. The patient has already maxed out their allowance for services – such as home visits or PT/OT.

Strategy for prevention: With the advent of the electronic health record, keeping track of where a patient is in terms of receiving a time-limited or amount-limited number of services within their coverage bracket should be easy. If you don’t already have something set up within the EHR in your office for these patients, talk to your superusers about creating a command that will help you track. Then you can alert patients when they are approaching the end of their coverage period for those services.

6. The claim form was submitted, but it was missing a modifier or had the incorrect modifier.

Strategy for prevention: If you don’t have stopgaps in your EHR already, find out how to get them programmed so that your coders will be prevented from submitting claims without modifiers.

7. An inpatient procedure was billed in an outpatient setting, or vice versa.

Strategy for prevention: Again, short of checking every single claim with your own eyes, find out if you are fully utilizing the capability of your EHR and coding software to have “stop signs” to make you reconsider questionable claims. Humans make errors, but computers can find them!

8. The service being billed for isn’t covered or there is a question of medical necessity.

Strategy for prevention: Medical Necessity edits are everyone’s worst nightmare, but they are a common reason for denied claims. Make sure that you understand what’s being covered, first and foremost, and if coders tell you that medical necessity edits are required, don’t shoot the messenger!

9. The claim is missing vital information, pre-authorization or the time period of submitting has been exceeded.

Strategy for prevention: Again, you should be able to either utilize or create some stopgaps in your computer system to help prevent the submitting of partially complete or unverified claims. Pre-authorization can be confirmed by most offices with a simple phone call!

10. The physician is an out-of-network provider, therefore, the insurer will pay less than they would if the physician was in-network.

Strategy for prevention: Unfortunately, this is a constant struggle not just for patients, but providers, no matter where you’re practicing medicine these days. For patients, the responsibility of knowing which of their many healthcare providers are in-network versus out-of-network can be daunting, but it’s helpful if healthcare provider offices can have the information readily available.

11. There is a coding error of some kind – it could be something like a mismatched code or two codes that cancel each other out.

Strategy for prevention: Again, utilize the power of your software to catch these things before claims get submitted. Don’t rely on the human mind to catch these things. Remember, coders are staring at these claims, codes and computer screens all day every day, let the computer be a second-set of eyes!

12. The patient may have dual-coverage, such as secondary insurance or worker’s compensation.

Strategy for prevention: Always verify the patient’s insurance status and if there are multiple levels of coverage, be sure that it is indicated in the chart or record when the patient is registered.

13. The deadline for filing the claim past – the claim might be completely accurate, but if it wasn’t received at the end of the time frame (which can be as little as 90 days) it will be rejected.

Strategy for prevention: Tracking dates for timely filing can be a pain, but missing those deadlines is an even bigger one when you consider how much money is to be lost for missing, unfilled or rejected claims.

14. There were typos during registration and some of the key demographic information, such as the patient’s name, address or date of birth, are incorrect.

Strategy for prevention: Computers help to catch some spelling errors, but it’s also important to make sure that coders and patient registration professionals are checking their work: spelling mistakes or even mis-typed zip codes can create a ton of problems.

15. The claim is using outdated CPT codes, or, incorrect CPT codes.

Strategy for prevention: With ICD-10 on its way in, everyone’s thinking about the challenge of assimilating new codes. CPT codes are no different. Be sure that your staff of coders are trained, that their training is current and frequent refreshers are offered and that you have created an atmosphere of personal accountability for the quality of the work.

These are just some examples and, as you can see, many of them could have been avoided by careful observation, a simple double-check of claim worksheets or updating current resources to reflect the requirements and standards we all must adhere to in today’s world.