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 of 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.
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 patient’s 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 Patient’s date of birth
- Incorrect subscriber numbers
- Incorrect subscriber group number
- Insurance ineligibility
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 before the primary care physician’s referral, then the claim will be denied.
Claim Was Filed After Insurer’s Deadline
If the claim is not filed before the insurer’s deadline, then it gets denied. Be aware of timely filing deadlines (TFL). Here are a few examples of timely filing deadlines.
United Health Care
Timely filing deadlines are mentioned in the provider’s 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.
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.
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