No medical billing company enjoys having denied claims. They result in lost revenue for your practice, and can often signal that there may be a problem brewing from within your practice as well. There are many reasons denials may occur and knowing where the origin of a problem is can help you get that problem resolved. Here are some common reasons practices have denials and solutions to these problems.
A Duplicate Claim Had Been Submitted for the Same Service or Procedure
Sometimes, the issue may be that a claim was already being processed. Because of this possibility, take a moment to check with your reports before you resubmit a claim. Learn why the claim did not get paid or if it was turned down by the clearinghouse.
Patient Is Ineligible for Services Because Their Health Plan Coverage Has Ended
Make sure you look at your patient’s insurance card so you can confirm their coverage. You should always copy both sides of their card so that you can make sure all the information you have is correct.
The Physician Is not an In-Network Provider
The provider needs to be approved by whoever the insurance carrier is. You need to submit and keep track of all the provider’s credentialing applications in accordance with their insurance plan requirements. Ensure that you follow up with the insurance payers on a regular basis to make certain that providers are currently enrolled in-network any time enrollment is open.
You Have Either Missing or Invalid Patient Information
Denials can often pop up because of incorrect or missing information about the patient. Before you file a claim, confirm that all the patient’s demographic and insurance information is correct. This includes the patient’s name, their vision and medical plan numbers, and their date of birth. If even one field does not have the correct information, this can cause denials.
The Benefit Exceeds the Permitted Number of Services or Visits
A lot of insurance payers will only permit a set number of services or visits each year. You will run into claim denials whenever patients go over this limit. That is why you have to confirm if your patient is eligible for their next visit or service beforehand.
Services Were Bundled Rather Than Having Them Billed Separately
Certain services cannot be filed separately, such as lab profiles that have multiple tests. This means they will have to be bundled. You will almost certainly run into denials if you accidentally bill these services independently.
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