The Top 5 Reasons Your Claims Are Denied (and What You Can Do to Fix Them)

Nothing throws a wrench in your revenue cycle quite like a growing list of denials. For your office, denials mean less money in the door, more work for your staff, and less consistency in your monthly AR.

The good news if you are struggling with claims denials is that the most frequent causes for those denials are surprisingly easy to correct. Here are the top five most common reasons for claims denials according to Healthcare Finance, along with what you can do to fix them.

Duplicates

Healthcare Finance states that the largest percentage of claims denials come from duplicates. More specifically, they are the result of practices resubmitting claims before having received the initial response back from their insurance payers. To minimize these occurrences, make sure to keep a firm handle on your claims inventory. Many practice management systems allow users to note activity on claims – instruct your users to leverage these features so that everybody in the practice can see what actions others have taken. It is also important to work your claims on a regular schedule and keep your rejection queues as organized as possible.

Incomplete Claims

User error affects everything, your claims included. According to Healthcare Finance, denials due to human error take almost twice the amount of work to correct and resubmit. Understanding your practice’s most commonly made mistakes will help you identify and prevent these sorts of errors ahead of time. Your clearinghouse should provide you with rejections reports for precisely this purpose. Adding a front-end claim scrubbing tool and keeping to your rejections schedule are additional steps you can take.

Expired Eligibility

As we have covered here before, verifying your patient’s insurance eligibility can have tremendous benefits to your practice. Case in point: Healthcare Finance cites expired insurance eligibility as one of the top five most common reasons for denials. Make sure you are taking advantage of an electronic eligibility tool through your clearinghouse and are performing eligibility checks on your patients when they arrive for their appointments, in addition to any checking you do when they schedule. A surprising number of eligibility expirations occur in the time between the phone call to schedule the appointment and actual check-in. To ensure all staff is aware of a patient’s eligibility status, make sure you notate the information relevant to your practice in your practice management system.

Not Covered by Insurer

Another important piece of information your eligibility verification will help with – a claim not being covered by the insurer. If you adopt a real-time eligibility tool, you will be able to recognize these situations beforehand and can discuss options with your patients prior to service. When high-dollar procedures are involved, make sure you follow up with insurance carriers via phone if your electronic eligibility response does not provide you with the specifics you need.

Timely Filing

Timely filing issues are addressed best through workflow and organization. Keep to your claims submission schedule, prioritize your high dollar claims first, and work your rejections promptly and in an organize fashion. By incorporating the tools discussed with the rest of these denial reasons, you can also minimize the chances claims are delayed at the clearinghouse level due to errors.

By checking eligibility, committing to submitting claims and working rejections promptly and regularly, and monitoring your claims rejections reports, you can minimize the impact that the top five denial reasons have on your practice.

Source: www.healthcarefinancenews.com/news/top-5-medical-claim-denials

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