Understanding Most Common Denials in Medical Billing

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Understanding Most Common Denials in Medical
Billing
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Understanding Most Common Denials in Medical
Billing
Basics of Claim Denials Managing claim denials is
the most challenging part of revenue cycle
management for any healthcare practice. As per
one of the survey reports from the Center for
Medicare and Medicaid Services (CMS), almost 30
percent of submitted claims are either denied,
lost, or ignored. Even the smallest medical
billing and coding errors could in claim denials
resulting in denied or delayed insurance
reimbursements. As a result, claim denials can
have a negative impact on your revenue and your
billing departments efficiency. In addition,
frequent errors can negatively impact the
relationship you have with patients and insurance
carriers. In this article, we share the most
common denials in medical billing so that you can
be well prepared to avoid them. Most Common
Denials in Medical Billing The Patients Coverage
was Terminated The most common denial you could
receive is Expenses Incurred After the Patients
Coverage was Terminated. This denial occurs when
the expenses were incurred after the patients
coverage had been terminated, meaning that your
practice provided health care services to a
patient after their insurance policys
termination. You can check to see if the patient
had any other active insurances at the time you
provided services. If not, then youll need to
bill the patient directly. The only way to avoid
this resolution is to verify insurance coverage
for every patient visit. The patients insurance
coverage report will help to find out whether
insurance is covering planned services,
co-payment amount, and any unpaid deductibles.
Your front office staff could provide benefits
reports for every patient visit and in case of
non-coverage, you can contact the patient about
non-coverage and send estimates for self-pay.
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Understanding Most Common Denials in Medical
Billing

• Diagnosis Inconsistent with Procedure
• Choosing diagnosis codes which is inconsistent
  with the procedure is also a very common reason
  for claim denial. The diagnosis code is the
  description of the medical condition, and it must
  be relevant and consistent with the procedure or
  services that were provided to the patient. Many
  times, this denial occurs because of a simple
  mistake in coding, and the wrong diagnosis code
  was used. Thats the first thing to check if you
  get this type of denial. Double-check with the
  coding department and the patients record to
  ensure there wasnt a typo or to ensure a
  diagnosis wasnt left out accidentally. If there
  were an error here, youd need to correct the
  claim, and then resubmit it as a corrected claim.
  If there was no error but you believe that the
  denial is in error, then you have the option to
  appeal the claim and provide medical records that
  back up the medical necessity of the procedure
  for this patients diagnosis.
• Timely Filling Limit Expired
• All insurance carriers have timely filing limits
  and expect that claims will be submitted within
  the specified time limit. When claims are not
  submitted during this time frame, they are denied
  for filing a claim after the time limit expired.
  Since youre likely working with a variety of
  insurance carriers, make sure that youre aware
  of each of their timely filing deadlines, since
  they can vary. For example, Aetna provides 90
  days for physicians have 90 days after the
  service date to submit the claim. For Cigna,
  out-of-network providers have 180 days after the
  service date to submit the claim.

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Understanding Most Common Denials in Medical
Billing

• Coordination of Benefits
• Sometimes patients are covered under multiple
  insurance plans so you need to understand the
  coordination of benefits rules. The coordination
  of benefits rules that decide which payer is the
  primary, secondary, and tertiary insurance to
  make sure that the correct payers pay and that
  duplication of payments doesnt occur. When
  claims are filed, they must be submitted to the
  primary insurance first. Then the balance is
  submitted to the patients secondary and tertiary
  insurance carriers. When this type of denial
  occurs, your first step should be to check
  eligibility and determine which of their
  insurances is their primary one. Then youll know
  better how to submit the claim to the correct
  insurer.
• Legion Health Care Solutions has a team of expert
  billers who scrub the claims clean and free them
  from errors before submitting them. Our coders
  are well-versed in CPT and ICD-10 coding,
  billing with code modifiers, electronic data
  interchange (EDI) processes, industry standards,
  and maintaining 100 HIPAA compliance. Decreasing
  claim denials helps your practice in delivering a
  consistent and positive cash flow. Please get in
  touch with us in case of any medical billing
  assistance on 727-475-1834 or email
  info_at_legionhealthcaresolutions.com

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