Insurance claim denials plague most hospital and medical practice billing offices, although to what extent can be hard to determine. There is a noticeable lack of information on the industry average for denied claims. Insurers are hesitant to release data about how often claims are denied, or for what reasons. So how can your billing staff know what to be on the lookout for when filing insurance claims?
We have compiled a list of some of the most common causes of insurance claim denials faced by our clients that can help you file more accurate claims. By keeping these common issues in mind your practice can attempt to reduce its denial rate – which the MGMA has stated should only be about 4%, on average.
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Errors that lead to denials can occur as early in the revenue cycle as pre-registration. Denials often result from outdated demographic or insurance information, or because necessary information is missing altogether.
When a patient calls for an appointment, be sure to verify insurance coverage and benefit eligibility over the phone, and reconfirm when they arrive for their appointment. There is a chance that their coverage could have changed, even in that short period of time. Additionally, implement a procedure for double checking all claims before submission to ensure that all necessary information has been completed. Pay special attention to the subscriber number and date specifics, which are often overlooked.
Lack of Specificity
Many payers are extremely detail-oriented, so despite the time of service often being hectic, it is important to pay very close attention to the details of the patient’s visit and to take your time when filling out claim forms.
Coding to the highest level of specificity is a great way to reduce denials. A diagnosis should be coded to the absolute highest level to ensure acceptance – meaning the code uses the highest number of digits available. Some billers are only minimally trained in coding, so facilitate a dialogue between them and your coders or providers to make sure they can identify truncated codes and can correct them prior to submission.
One of the easiest causes of insurance claim denials to avoid is untimely filing. Every payer operates on its own filing deadlines and it can be easy to miss a filing window if you aren’t careful. Have your billers keep a list of general payer deadlines handy. Organizing and filing claims by payer will help to ensure that each one receives its claims in a timely manner.
Also, when possible, track and document each payer’s claim receipts. Sometimes claims are unfairly denied for timing so keeping track can help keep the payer accountable to its own deadlines. Filing many claims for the same payer at once can also help make the process of tracking receipts less cumbersome.
Know Your Payers
Many denials are the result of simple errors within your billing process, but sometimes it is changes to the payer’s organization that can create issues. A payer may make changes to its system or requirements without alerting you – for example, requiring more detailed demographic information as of a certain date. In these cases, categorizing your claims by payer can again be helpful. If there is a payer-related issue it is easier to spot if it is consistent within multiple claims that are all being worked at the same time.
Not only does denial management take up much of your staff’s valuable time, it can cost as much as $15 per claim to follow up. Keep these common issues in mind when submitting your claims and start reducing the need for costly appeals.
Want more tips on dodging denials? We made you a guide.
Written by Ali Bechtel, Marketing Manager
This information is not intended to be legal advice and may not be used as legal advice. Legal advice must be tailored to the specific circumstances of each case. Every effort has been made to assure this information is up-to-date as of the date of publication. It is not intended to be a full and exhaustive explanation of the law in any area, nor should it be used to replace the advice of your own legal counsel.