Claims processing is a complex business. Insurance providers do not like to pay for medical expenses and have made reimbursement as difficult and time consuming as possible.
The goal is to file claims that are both accurate and completed in agreement with payer stipulations to optimize reimbursement. It's possible to have a "clean" claim, but roughly 16% of claim reimbursements are denied or delayed.
Want a much more detailed guide to denials and appeals? We recommend you have a look at the ebook Denials, Appeals & Adjustments, written by 2 experienced medical billers.
Delay means time, and time means money!
Incorrect patient information - Patient information is potentially the most important.
Check and recheck the patient information against the information used on the claim form. The wrong middle initial can result in a denial.
Avoid using asterisks or dashes in the ID numbers. Have a copy of the front and back of the patient's insurance cards (both primary and secondary insurances) and ask for any new information each time they come to the office.
Treatment not covered by the insurance policy - Claims will be denied if the services rendered are for procedures not covered by the patient's insurance policy. It is important that you check with the insurance provider prior to seeing the patient.
Procedures regarded as not medically necessary - In some cases, insurance providers will determine a procedure to be medically unnecessary. Always check with the patient's insurance company before any service is provided. Supplying additional documentation as to why the procedure is necessary may help avoid a denial.
Claims not filed in a timely manner - Health care providers are required to file claims within 1 year (365 days) of the date of service.
If you are sending your claims by mail, be sure to send it as a certified letter. This will enable you to recall the exact date in which the claim was sent out. Also, keep all of your receipts. If an insurance company denies your claim due to a time issue, a receipt can provide the actual date it was sent.
Treatment done without prior authorization - ALWAYS GET AUTHORIZATION BEFORE SCHEDULING A PROCEDURE. This is especially important for major procedures, such as surgery. If you fail to do so and your claim is denied, reimbursement may not be an option and there goes your raise.
Invalid diagnosis/procedure codes - ICD-9/CPT codes can be very complicated and it is easy to file a claim with incorrect codes. Check and recheck your work. Be careful with your secondary codes. A claim can be denied because of an incorrect or invalid secondary code. Be sure to read ALL the notes included with the codes.
If you are familiar with the procedure and diagnosis codes for a specific service do not report them without looking them up first. It is a common mistake to code directly out of the index.
If you are not familiar with a procedure or a diagnosis, ask the physician you work for. He or she should be able to give you enough information regarding the procedure and diagnosis to help you code them correctly.
Use of incorrect forms - There are 2 universally accepted claim forms - the CMS 1450 (UB-04) and CMS 1500. You should be familiar with both forms and what situations they are used for.
Coverage was terminated, lapsed, or not in force at the time of service - Unfortunately this does happen.
Often the patient is unaware of the situation until they receive the bill for services rendered. Always check with the insurance provider to determine if the patient is covered at the time of service.
Duplicate claims - Sometimes the same treatment is provided on the same day to the same patient. Insurance companies may see this as a duplicate claim and automatically deny it. Make sure to add appropriate modifiers and check for any additional codes that may be needed. Additional documentation may also be required.
Improper use of modifiers - There are plenty of modifiers to consider for different procedures. Review them and become as familiar as possible with each one.
Most importantly, do not rely on what you THINK you know about a modifier. Review modifier notes before you assign one.
Patient not eligible for coverage - Children are covered under their parents' insurance plans until a certain age. That age is not universal for the different types of insurance plans.
Be sure to check with the insurance provider to determine if the child is covered under the parents' plan and to what age that coverage is offered.
Unreasonable Fees - Insurance companies have a schedule of the medical fees for various services provided in your area. When they receive a claim that is not within those guidelines, they are able to deny the claim.
Again, follow the detail of the codes required and properly use each modifier as needed.
Be careful!! Too many of these types of claims could be interpreted as fraud and bring unwanted attention to the practice/facility. See this article on fraud in the billing community.
Rules and regulations set forth by different types of insurance companies make claims billing problematical. Even the most experienced medical billers and coders still find insurance claims to be tricky. Don't get discouraged if you find the information a bit overwhelming!
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