For healthcare providers, solving insurance claims often resembles solving a complicated puzzle. Denied claims not only impede the financial growth of a practice but also interfere with the proper payment for the necessary services provided. The consequences go beyond delayed payments to higher operational costs and a possible financial burden on patients. Hence, there is an urgent need to immediately deal with claim denial issues.
This blog talks about the top ten reasons for insurance denials in medical billing. Most importantly, it offers practical tips to enable healthcare providers to identify and correct these errors.
Reasons for Insurance Denials and Ways to Avoid Them
Following are the top 10 mistakes to avoid while making a claim submission. Possible ways to avoid these mistakes are also discussed.
Incomplete Patient Information
One of the crucial mistakes we noticed is the incomplete patient information. Submitting wrong or insufficient information often leads to claim denials. Mistakes in details, such as misspelling names or giving erroneous information, may cause problems. All details must be thoroughly verified by the healthcare providers. Healthcare providers need to ensure that the data on the insurance form is accurate and adequate.
How to avoid this mistake?
To avoid this issue, providers must adopt a systematic attitude towards insurance documents. First, check the review forms carefully for mistakes. Secondly, develop a list that highlights important points and necessary documents. Lastly, ensure accuracy by cross-checking information and paying keen attention to details. A professional denial management service will always take care of patient information before submitting patient claims.
Mistake 2: Lack of Pre-authorization
Lack of pre-authorization is another mistake that leads to claim denials in the healthcare billing. Before providing any medical care, healthcare providers must verify it with the insurance company. Failure to carry out this step will lead to denials or rejections.
How to Avoid this Mistake?
Providers should adapt the practice of contacting the payer prior to providing medical care. By doing so, the healthcare provider protects himself from the possibility of rejection. If you are busy with patient care and don’t have enough time, then you can also take help of a professional prior authorization service provider.
Mistake 3: Out-of-Network Providers
Another common mistake leading to insurance denials is seeking services from doctors outside the insurance network. The choice of an out-of-network doctor may result in lower coverage or even the denial of the claim. In other words, this means a visit to a doctor that is not usually covered by the patient’s insurance.
How to Avoid this Mistake?
To prevent this issue, patients should consult only those physicians who are in their insurance network.This ensures that the patients are fully covered by their insurance policy.
Before scheduling an appointment with him, patients must ensure that the healthcare provider is in-network. This small step can save physicians from potential rejections and unexpected costs.
Mistake 4: Expired or Inactive Coverage
The most frequent cause of insurance denials is expired or inactive coverage. In other words, if your insurance is inactive, your claims can be rejected.
How to avoid this mistake?
In order to prevent this problem, it is important to monitor the coverage of the insurance periodically. Make sure that the patient’s policy is still valid and has not lapsed. This move can help prevent unjustified rejections and ensure that the insurance is ready to cover the patient when necessary.
By doing regular status reviews of patients’ coverage, healthcare providers stay informed and avoid complications in the claim process.
Mistake 5: Missed Filing Deadlines
A common error that results in insurance denial is failing to keep filing deadlines in mind. Basically, failing to file the insurance claims within the time frame leads to the rejections. In other words, “it means failure to submit on time.”
How to avoid this mistake?
To overcome this problem, it is important to be aware of and comply with insurance company’s deadlines. These deadlines work like a due date for the papers. Thus, healthcare providers can easily minimize the margin of error by submitting claims on time.
Mistake 6: Discrepancies in Medical Coding
Another frequent mistake that usually results in denials is coding disparities. This happens when the codes used to define medical services are inaccurate. In other words, there are errors in the numbers or letters that symbolize the medical treatments provided to the patients.
How to avoid this mistake?
To avoid this problem, healthcare providers first confirm all the codes connected to the medical services. This process guarantees that the information is a true representation of the care rendered. Attention to the coding details can help avoid unnecessary denials by healthcare payers.
Mistake 7: Non-Covered Services
Seeking non-covered service is also another prevalent cause of insurance denials. When patients ask for medical care that their insurance does not cover, this happens. In other words, it is an attempt to seek services that the insurance plan does not cover.
How to avoid this mistake?
In order to avoid this problem, it is important to know what services are covered under the patient’s insurance policy. Read the policy documents in depth. Call the insurance company to understand the details of the coverage.
Knowledge of the coverage supports choices that reflect the insurance benefits. Thus, it minimizes the issue of claims rejection.
Mistake 8: Duplicate Claim
Duplicate claim submissions are a frequent occurrence that can result in insurance denials. This happens when the healthcare provider submits the same service multiple times. In other words, it is to unknowingly ask the insurance for payment of the same thing at different times.
How to Avoid this Mistake?
To eliminate this problem, consider carefully when submitting a claim and do not copy any services. Keep track of the claims that you have already filed to ensure that you don’t file the same information. Make use of systems that allow you to control and sort out your claims, so as not to mistakenly reproduce them. Noting these details can help you avoid the risk of denials and simplify the claims process.
Mistake 9: Upcoding and Downcoding
Upcoding or downcoding results in insurance denials. In upcoding, healthcare providers assign higher-level billing codes which actually demands a lower level of coding. Thus, there is an increase in the organization’s reimbursement. Contrastingly, Downcoding refers to the practice of coding at a lower level than the services actually delivered to the patient. Since the codes do not accurately represent the services provided, both practices result in insurance issues.
How do I avoid this mistake?
To avoid this issue, healthcare professionals should focus on proper coding practices. Regular training and information for coding staff can increase awareness of proper coding regulations. Physicians should Internally audit and review the claims to address discrepancies. Moreover, open communication between coding staff and healthcare providers guarantees the true reflection of the services rendered.
Mistake 10: Insufficient Medical Necessity
Lack of perceived medical necessity for the rendered services is also one of the reasons claims are denied. In other words, the insurance company doubts whether a particular treatment or procedure was medically required or not.
How to Avoid this Mistake?
To avoid medical necessity issues, providers should focus on effective documentation and communication. Make sure that the medical necessity of each procedure is fully documented in patient records. Promote free discussion with patients on the need for proposed therapies. Work with the patients to provide further information or clarification on why the treatment is necessary when preparing claims.
Conclusion
In short, the avoidance of mistakes in insurance claims is just a shortcut to a smooth ride. You can avoid denials with the help of a check list this include down and upcoding coding are the most impoortant. Remember, consistent communication and precise information count.
Working with a trusted medical billing company, such as Medheave, can even further simplify this process for healthcare providers. They help with the gritty work of billing, minimizing errors and denials so that providers can do what they are best at—taking care of patients. Make a good choice, and insurance claims will become a smooth process for all. Contact us for further details.
