Denials in medical billing are when an insurance company refuses to cover for certain medical expenses due to a variety of different reasons.
Denials in medical billing are not only a hassle for a company’s emergency medicine group but are also a considerable drain on an ED’s efficiency and operations, thereby causing significant revenue expense.
Despite extensive denial management efforts, medical billing denials are a common and widespread inconvenience that plagues various companies and organizations, and thus this article aims at targeting the common reasons for medical claim denials as a means of overcoming them.
Let’s delve into the complex world of medical billing denials in order to comprehend and overcome them! Common Reasons for Medical Claim Denials
Missing information
Missing information is the most common reason behind medical billing denials. Studies show that missing information is behind more than 60% of medical billing denials and approximately 42% of denial write-offs. Even a single required field left blank – ranging from modifiers and addresses to social security numbers – can trigger a medical claim denial.
Services not covered by payer
Services that are charged for but not covered by a payer typically trigger a medical claim denial. This usually happens when staff do not check with a patient’s insurer to ensure that their current benefit plan covers the services and procedures provided.
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Claims considered duplicate are automatically flagged and denied. This happens when the submitted claims have the same performed services, beneficiary, healthcare provider, or the date of service provision.
Already adjudicated services
Medical billing claims get denied when benefits for one procedure or service get lumped into the allowance or payment for another already paid for process or service.
Insurance companies generally have a strict time window for claim filing and particular deadlines for ED groups to submit reworked medical claims. Claims that get sent in after the deadline get denied.
Transcription errors
In the medical billing world, a simple typo can cost a considerable amount of money. Since doctors are notorious for having bad handwriting, information transcribed from their writing to medical claims has a high chance of containing errors. Be it a misspelled patient name, incurred billing code claim, or wrong date of birth, a claim is likely to be denied.
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It is relatively common for consumers to change health insurers at least once every one or two years, owing to the changing rates and new providers entering or exiting the marketplace. Therefore, it is ubiquitous for medical billing claims to get sent to the wrong company, which causes denials. It is pertinent to thoroughly check service dates and coverage before sending a claim to ensure it goes to the right company.
Patient obligation
Medical claims may get denied and coded as a patient obligation, which may refer to a variety of notions. However, many denials specify the particular contractual complication that leads to the rejection, which may include a patient not meeting their deductible, the claim lacking the basic information required to determine its coverage, an uncovered service, or a patient required to seek a referral or care covered by some other insurer.
Several health insurance companies have their own contracts with healthcare providers, and some medical billing claims may get denied when they fail to meet the agreed billing requirements. A denied billing claim with the reason labeled contractual obligation points to an error in satisfying one of the insurer’s hoops. This may occur if a claim is not filed timely, a submitted claim fails to support service necessity, the provider either provided too many services or was not certified to do so, or the claim was already paid.
Overlapping claims
Overlapping claims occur when one claim’s service period overlaps with that of another. This is quite different from duplicate billing and often occurs when a patient seeks healthcare from more than one provider. If a denial offers adequate information about the overlap, it is possible to fight it. Now that you are aware of the most common medical billing denials, you can devise an elaborate plan to prevent them. However, devising such strategies can be an arduous process, and that is why SmartClinix is here to help.
If you are looking to avail of professional medical billing services, SmartClinix can help you in the prospect while lowering your denial rate, skipping AR delays, and increasing your revenue, all for as low as 3.9%. Experienced medical billing teams at SmartClinix offer smart medical billing services for enhanced cash flow and can manage your complete revenue cycle, ranging from claim submissions to denial management. SmartClinix offers multifaceted services from professionals experienced in various EMR and EHR services. Our billers understand your specialty requirements and thus offer specialized services at par with them, ensuring elevated cash flow for your practice. Head over to SmartClinix to know more and avail of these outstanding services at the minimum cost!
Dr. Josh is a physician who's helping spread the knowledge about Telehealth and its advantages. At SmartClinix, he's providing his expertise and knowledge in the form of engaging articles on various health & tech related topics.
Dr Josh
September 1, 2022
medical billing
