Denied claims are one of the leading causes of lost revenue in a medical practice. By understanding why insurance claims are being denied, your practice can significantly improve it’s claims acceptance rates. If you see a denial rate over 5% you should consider looking at the reasons why your claims are being denied and what the best solutions may be. Here are some of the top reasons insurance claims are denied.
Missing or incorrect information:
Information collected during the check in process such as patient demographics and insurance information is critical the claim’s approval. Often time we see claims being denied because of missing patient information or having incorrect information. Even the most basic details such as the correct spelling of names addresses and DOB can cause a denial. It is critical to have a thorough process making sure none of this information is missing and all of it is entered correctly. Some PM systems will allow you to pull information directly from the insurance provider making sure all the information is correct and complete. Other information such as date of service and provider identifier number is also critical to a clean claim.
On many occasion a claim can come back denied because of expired or changed coverage. It is important to verify that the patient insurance has neither changed nor expired prior to service. Further, you should check for coordination of benefits if a patient has multiple insurance plans.
Coding and Proper Documentation:
Another critical component is to file each claim with the correct HCPCS codes. These codes are updated on a regular basis changing some of the codes and adding or removing others. Make sure that whoever is coding your claims is up to date on the newest set of codes. Some claims must also be filled with the supporting documentation in order to adjudicate the claim. These documents may include medical record, consultation record, patient physical records and radiology reports.
Missing Prior Authorization:
Many services require that the provider obtain prior authorization before rendering services. This will usually apply to services that are not considered an emergency and usually incur a high expense such as radiology services including MRI, CT, and Ultrasound as well as surgical procedures.
Time limits for filling a claim are set forth by insurance carriers. The limits often vary from as little as 90 days to as many as 180 for physicians. Some carrier allow up to a year for hospitals.
Looking within your practice and determining areas to improve is the right place to start. making sure your staff has the right tools to perform at their best is a good idea. Having a Practice Management system that will help your staff rather then make their workflow harder should be a priority, just as a easy to use and intuitive EHR is a priority for physicians. Outsourcing your billing process may be a more affordable solution for many.