Understand Claim Denials Affecting Reimbursement in Healthcare

To understand claim denials affecting reimbursement requires data. In healthcare, claim denials occur when an insurer or payer refuses to reimburse a healthcare provider for a particular medical service or treatment. Denials occur for a variety of reasons, such as inaccurate or incomplete billing information, lack of medical necessity, or failure to follow the proper billing procedures. These might result in significant financial losses for healthcare providers and can also affect patient care. In this article, we will discuss the types of claim denials that affect reimbursement in healthcare.

Most Common Reasons

1. Administrative Errors: Administrative errors are one of the most common reasons for claim denials in healthcare. These errors occur when healthcare providers submit inaccurate or incomplete billing information, such as missing patient information, incorrect diagnosis codes, or incorrect billing codes. These errors can be avoided by ensuring that all necessary information is accurately captured and entered into the billing system.
2. Medical Necessity: Medical necessity denials occur when a healthcare provider submits a claim for a service or treatment that is not deemed medically necessary. Insurance companies often have strict guidelines on what is considered medically necessary, and if the service or treatment does not meet these guidelines, the claim may be denied. It’s important for healthcare providers to thoroughly document the medical necessity of each service or treatment to avoid these types of denials.
3. Coding Errors: Coding errors occur when a healthcare provider submits a claim with an incorrect billing code. This can result in the claim being denied or underpaid. To avoid coding errors, healthcare providers should ensure that they are using the most up-to-date coding guidelines and that they have a system in place to check for errors before submitting claims.
4. Timely Filing: Timely filing denials occur when healthcare providers fail to submit a claim within a specified timeframe. Insurance companies typically have strict deadlines for claim submission, and if the claim is not submitted within the allotted time, it may be denied. Healthcare providers should ensure that they have processes in place to submit claims in a timely manner.
5. Coverage Limitations: Coverage limitations denials occur when a healthcare provider submits a claim for a service or treatment that is not covered under the patient’s insurance plan. Insurance companies often have restrictions on what is covered under their plans, and if the service or treatment is not covered, the claim may be denied. Healthcare providers should verify insurance coverage before providing services to patients to avoid these types of denials.
6. Duplicate Claims: Duplicate claims occur when a healthcare provider submits multiple claims for the same service or treatment. This can result in the claims being denied or underpaid. To avoid duplicate claims, healthcare providers should ensure that they have a system in place to track claims and that they are submitting each claim only once.

Understand claim denials..

…are a common occurrence in healthcare, and they can have a significant impact on a healthcare provider’s revenue cycle. By understanding the types of claim denials and implementing processes to avoid them, healthcare providers can improve their reimbursement rates and provide better care to their patients. Below are excellent articles on the subject from:

beckershospitalreview.com 
revcycleintelligence.com
healthcarefinancenews.com