Avoiding Claim Rejections
Every claim your practice submits to insurers has the potential to sustain or subvert your health care organization. Accepted claims get you paid so you can maintain a profitable practice. Too many claim rejections or denied claims can kill it by disrupting or delaying your income.
And even if you think you and your staff are doing everything right for claims management success, there are a few common mistakes it’s all too easy for practices to make. Need proof? Studies show billing denial rates range from 5 to 10 percent for the average practice, with some rates rising as high as 15 to 20 percent. In this article, we shared examples of common claim rejections and their possible solutions.
Claims often get denied because a patient wasn’t eligible under their current insurance coverage to receive a health service you provided. This can happen when there’s been a policy update within a patient’s plan or coverage for a particular service expired.
Before you try to bill the patient for the full cost of treatment, it’s worth asking them to contact their insurer. Have the patient call their insurance company and ask for reconsideration. To avoid this situation entirely, it’s very important to verify insurance eligibility before treating a patient.
a two-physician practice should spend 1-2 hours per day performing eligibility verification. You can verify patient coverage through an insurer’s website, by calling the company’s hotline, or by using medical billing software.
Duplicate billing usually happens when someone at a physician’s office makes a mistake. Staff may not realize someone else already submitted a particular claim before sending it off.
If they show a payment has already been made for that service, then there’s no need to follow up with the insurance company and you should focus on finding out why there was a mix-up among your billing staff.
That said, there are cases where you may have to reach out to the payer for a resolution. Some of the possible scenarios might be:
- Unbeknownst to you, your patient received the exact same service from a different health care provider on the same date.
- You resubmitted a claim that hadn’t been paid within 60 days to avoid “timely filing denial issues.”
- The insurance company’s payment was sent to the wrong location.
- Different payers have different policies for dealing with these scenarios, so your best bet is to get a representative on the phone to determine the next steps.
You entered an incorrect or inadequate ICD-10 code for one or more services, so your claim got rejected.
Because of the potential for coding errors, it’s incredibly important for physicians to document patient encounters as comprehensively as possible. Keep detailed records with information, such as laterality, severity, and accompanying conditions to inform the codes you use.
If you have the documentation to support the codes in your claim, you’ll be able to appeal a rejection.
Coding errors usually fall into three categories:
- Upcoding: you assign billing code(s) for a more expensive medical procedure or treatment than the one(s) you actually performed. This is illegal because it results in greater revenue for services that weren’t performed.
- Under-coding: Your claim doesn’t include codes for services that you did perform. This is also illegal, though some physicians under-code to avoid audits or decrease a patient’s bill.
- Insufficient specificity: Your code isn’t specific enough. ICD-10 codes are more complex and allow for greater detail than the previous code set.
Data Entry Errors
There’s incorrect information in your claim and you didn’t catch it until it was already submitted.
Before submitting a claim, you should double-check whether the following information is accurate:
- The physician’s name, address, and phone number
- The patient’s name, sex, birthday, and insurance information
- The insurance company’s address and policy number
If your claim has already been rejected or denied because of a data entry mistake, you can always call the insurer and ask for reconsideration. Claim denials can often be resolved over the phone, but you can also submit an appeal in writing.
Before writing an appeal, check whether the insurance company has guidelines (e.g., procedures or timeframes) for sending an appeal. Appeal letters should include documentation that can serve as evidence and should be sent using certified mail.
Insurance companies make mistakes, too. If you’ve already reviewed the accuracy of your coding, data entry, and documentation, then it’s entirely possible that the payer processed your claim incorrectly.
Call the insurance company to figure out why the claim was denied. You can ask them for reconsideration if you think it was processed incorrectly, or you can write a formal appeal. It’s unfortunate, but these kinds of payer glitches are not uncommon.
Sometimes a payer requires medical records before it can adjudicate a claim. This may include the patient’s medical history, physical reports, physician consultation reports, discharge summaries, radiology reports, and/or operative reports.
No documentation means no services performed.
Referral or Prior Authorization
Some payers require you to obtain authorization or a referral from another physician prior to certain services or procedures being performed.
The primary care physician, who sends the patient to another healthcare provider for treatment or tests, issues a referral. The payer to perform the necessary service(s) issues a prior authorization. It is understood by carriers that obtaining prior authorization is still not a guarantee of payment. The submitted claim must still be
- Supported by medical necessity
- Filed within the timely filing requirements
- Filed by the provider mentioned in the referral or authorization
Avoiding claim rejections is really easy if you pay attention to the above-metioned points. The real issue comes when you are busy in patient care and don’t have sufficient time to examine each and every claim. That’s where we can help you. We have customized plans for every medical service provider. To know more about medical billing services provided by E2E Medical Billing Services call us at 888-552-1290 or write to us at [email protected]