Top 7 Reasons Behind Claim Denials

Claim denials pose threat to financial well-being of medical practices. So, it is essential to develop an error-free claim submission process to get reimbursements on time. In addition, pending payments due to claim denials create problems for your healthcare practice. For smooth-running operations and seamless revenue cycle process, medical practices need to streamline billing and coding. There are several reasons that lead to claim denials from incorrect claim submission to duplicate claims. In this article, we will discuss the top reasons behind claim denials.

Inaccurate Patient Information

The most important part of claim submission is the patient information. It includes the name of the patient, the ID number, insurance policy details, address, etc. Similarly, all this information should be 100% accurate and there is no room for error. Making an error in this information leads to claim denial.

Eligibility Verification Problems

If a healthcare provider renders a service that is not covered by the patient’s service, it means that physician has offered an unauthorized service. As a result, incorrect claim results in denials and create problems for the revenue cycle. So, medical practices should consult the insurance companies before rendering services to the patients.

Incorrect ICD/CPT Codes

Submitting claims with incorrect codes lead to denials. The billing staff must be aware of the latest CPT codes and submit clean claims. It is the best way to manage denials. In addition, using correct modifiers elaborating the procedure completely results in clean claim submission. So, accurate codes and modifiers are required to submit clean claims.

Duplicate Claims

When healthcare staff submits duplicate claim, it gets rejected. Since the insurance company has already paid for the service rendered on the same date, the duplicate claim gets rejected. Similarly, billers and coders should pay attention on the claims while submitting to payers. In addition, billing staff needs to spend time and effort on resubmissions, so it is better to check twice before submitting to payers.

Wrong Payment Details

Billing staff needs to stay updated with the payments for specific services. Incorrect payment details lead to claim denials. Additionally, making mistakes while entering the details of payments may delay the reimbursements. So, make sure the billed amount is absolutely correct.

Physician Credentialing Issues

If the physician is not credentialed, the claim will be denied by the insurance payers. So, it is essential for physicians to get affiliated with payers and complete the credentialing process. Staying registered with the payer allows providers to get payments seamlessly.

Claim Submission Delays

Medical practices should submit claims during the defined timeframe of the insurance payers. In addition, submitting the claim within the 30 days from the time of service reduces the chances of denials. As a result, it helps to establish a smooth revenue cycle process.

Conclusion

Healthcare providers should avoid these reasons to prevent claim denials and maintain a smooth cash flow. Errors in coding, incorrect patient data, wrong payment details, and not knowing the details of patients’ eligibility cause revenue losses. So, medical practices need to avoid these issues to avoid the stress of losing potential revenue.