Most Common Reasons for Medical Billing Claim Denial

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Most Common Reasons for Medical Billing Claim
Denial
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• Medical billing claim denials affect physician
  practice and cash flow.
• By reducing the claim denials rate, you can
  enhance your practice profitability and reduce
  administrative costs.
• To overcome the issue with a claim denial, it is
  important to understand the common reasons for
  claim denial.
• Let us discuss the most common reasons
  for medical billing claim denials.

Introduction
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Incorrect Patient Identifier Information

• Patient identifier information is the most
  important one to submit a medical claim with
  precise patient identifier information that helps
  the health insurance company to find the
  patients health insurance plan to make payment.
• Most of the claims denied because of inaccurate
  patient identifier data are
• Incorrect subscriber or patient name 
• Incorrect subscriber or Patients date of birth 
• Incorrect subscriber numbers 
• Incorrect subscriber group number
• Insurance ineligibility

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No Referral on File

• Most of the insurance companies adopted the
  referral process. If the patient has not got a
  referral from their primary care physician, then
  the physician should not provide service.
• In such a case, the claim is submitted prior to
  the primary care physicians referral, then the
  claim will be denied.

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Claim Was Filed After Insurers Deadline

• If the claim is not filed before the insurers
  deadline, then it gets denied. Be aware of timely
  filing deadlines (TFL). Here a few examples of
  timely filing deadlines. 
• United Health Care
• Timely filing deadlines are mentioned in the
  providers agreement.
• Aetna
• Physician The claims must be submitted within 90
  days from the date of service.
• Hospitals The claims must be submitted within
  one year from the date of service.
• Tricare
• Claims must be submitted within one year from the
  date of service.

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Missing or Invalid CPT or HCPCS Codes

• For the medical claim process, the healthcare
  industry uses standard codes to point out
  services and procedures.
• This coding is called Current Procedural
  Terminology (CPT) or Healthcare Common Procedure
  Coding System (HCPCS). These codes change
  frequently.
• So it is important to ensure whether your medical
  coder stays up to date with revised codes.

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Lack of Documentation to Support Necessity    

• If the payer is not confident of the medical
  necessity of the procedure, the claim will be
  denied. In such a case, they may require an
  additional document to adjudicate the claim. For
  that, medical records include the following
  items
• Patient medical history
• Patient physical reports
• Physician consultation reports
• Patient discharge summaries
• Radiology reports
• Operative reports

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