Handling health insurance claim denials quickly and well in the healthcare money process is essential. A claim denial happens when a health insurance company or Medicare says “no” to a doctor’s request to pay for their services. No matter why it happens, a claim denial can mean the provider does not get paid on time or at all.
This can cause revenue problems for hospitals, clinics, and other healthcare practitioner, making it hard for them to keep running smoothly. So, managing rejections is a big part of healthcare administration or the medical billing services handling this. It also shows the importance of getting medical billing and coding right.
In this article, we will explain how managing rejections works, discuss the different kinds of claim denials, and share some tips for doctors and their billing and coding teams on reducing or stopping them.
What is Denial Management?
Claim denial management in medical billing involves finding and fixing issues that cause medical claims to be denied. It includes handling denied claims and stopping future denials so healthcare practices get paid on time.
What are the Common Reasons for Claim Denials?
Here are some common reasons for claim denials when submitting a claim for reimbursement.
Getting the codes wrong
One big reason claims denials is incorrect codes. This happens when the code used does not match the service or diagnosis correctly. Before sending in a claim, it is crucial to double-check all the codes to make sure they match the services given and the patient’s diagnosis.
Missing Or Incomplete Information
Sometimes, claims are denied because they need more essential details. These could be information about the patient, the clinics, or the services provided. To avoid this, double-check all the information before sending in the claim.
Some insurance plans require prior approval for specific treatments or services. If you have this approval, your claim might be accepted. It is essential to determine if prior authorization is needed from the patient’s insurance plan and get it if required.
Not getting permission beforehand.
Many insurance plans require approval before performing specific procedures or services. To get paid, you must submit a claim with this prior approval. It is crucial to ask the patient’s insurance if you need this approval and get it if needed.
Services not paid for
Insurance plans often don’t pay for certain services. To ensure it is accepted, you must submit a claim for a service not covered by the patient’s insurance. To avoid this, check what services the patient’s insurance covers and get prior approval if needed.
Duplicate Claims
Sometimes, claims are turned down because they’re copies of already sent in. This happens when a provider sends the same claim more than once or if both the provider and the patient send it. To avoid this, it’s important to double-check all claims before sending them and ensure there are no duplicates when resubmitting denied claims.
Timely Filing
Timely filing means sending in claims before the deadline set by insurance plans. If a claim is sent in late, it’s likely to be denied. These deadlines vary depending on the insurance plan, usually 30 days to several months after the service was provided.
To keep the medical practice financially healthy, it’s crucial to prevent denials due to late filing. Claims denial means lost money and more work for the administrative staff. After providing the service, it’s best to submit claims immediately. This can be done using efficient billing processes, like electronic submission and tracking systems.
Sometimes, providers can ask for more time to file if there is a good reason why the claim could not be sent on time. But this is only sometimes an option and should not be relied on regularly.
Mistakes in Patient Information
Patient information errors are a major reason insurance claims in medical billing are rejected. This happens when the information provided about the patient needs to match what the insurance company has on record. It can happen because of mistakes in the patient’s name, birthdate, or insurance details.
To avoid this problem, it’s crucial to double-check all patient info before sending in a claim. This means having sound systems for registering patients and keeping their records current.
It’s also essential for healthcare providers to keep track of any changes in a patient’s insurance coverage. This could involve staying in touch with patients to know if anything has changed or using electronic systems to check insurance details. By staying on top of this, providers can ensure they’re sending claims to the right insurance company, increasing the chances of getting them approved.
Conclusion
Billing mistakes can cause problems for both healthcare providers and patients. Knowing the common reasons for these mistakes and avoiding them is critical to keeping a medical practice financially healthy.
