Understanding Most Common Denials in Medical Billing

Understanding Most Common Denials in Medical Billing

Basics of Claim Denials

Managing claim denials is the most challenging part of revenue cycle management for any healthcare practice. As per one of the survey reports from the Center for Medicare and Medicaid Services (CMS), almost 30 percent of submitted claims are either denied, lost, or ignored. Even the smallest medical billing and coding errors could in claim denials resulting in denied or delayed insurance reimbursements. As a result, claim denials can have a negative impact on your revenue and your billing department’s efficiency. In addition, frequent errors can negatively impact the relationship you have with patients and insurance carriers. In this article, we share the most common denials in medical billing so that you can be well prepared to avoid them.  

Most Common Denials in Medical Billing

The Patient’s Coverage was Terminated

The most common denial you could receive is ‘Expenses Incurred After the Patient’s Coverage was Terminated’. This denial occurs when the expenses were incurred after the patient’s coverage had been terminated, meaning that your practice provided health care services to a patient after their insurance policy’s termination. You can check to see if the patient had any other active insurances at the time you provided services. If not, then you’ll need to bill the patient directly. The only way to avoid this resolution is to verify insurance coverage for every patient visit. The patient’s insurance coverage report will help to find out whether insurance is covering planned services, co-payment amount, and any unpaid deductibles. Your front office staff could provide benefits reports for every patient visit and in case of non-coverage, you can contact the patient about non-coverage and send estimates for self-pay.

Diagnosis Inconsistent with Procedure

Choosing diagnosis codes which is inconsistent with the procedure is also a very common reason for claim denial. The diagnosis code is the description of the medical condition, and it must be relevant and consistent with the procedure or services that were provided to the patient. Many times, this denial occurs because of a simple mistake in coding, and the wrong diagnosis code was used. That’s the first thing to check if you get this type of denial. Double-check with the coding department and the patient’s record to ensure there wasn’t a typo or to ensure a diagnosis wasn’t left out accidentally. If there were an error here, you’d need to correct the claim, and then resubmit it as a corrected claim. If there was no error but you believe that the denial is in error, then you have the option to appeal the claim and provide medical records that back up the medical necessity of the procedure for this patient’s diagnosis.

Timely Filling Limit Expired

All insurance carriers have timely filing limits and expect that claims will be submitted within the specified time limit. When claims are not submitted during this time frame, they are denied for filing a claim after the time limit expired. Since you’re likely working with a variety of insurance carriers, make sure that you’re aware of each of their timely filing deadlines, since they can vary. For example, Aetna provides 90 days for physicians have 90 days after the service date to submit the claim. For Cigna, out-of-network providers have 180 days after the service date to submit the claim.

Coordination of Benefits

Sometimes patients are covered under multiple insurance plans so you need to understand the coordination of benefits rules. The coordination of benefits rules that decide which payer is the primary, secondary, and tertiary insurance to make sure that the correct payers pay and that duplication of payments doesn’t occur. When claims are filed, they must be submitted to the primary insurance first. Then the balance is submitted to the patient’s secondary and tertiary insurance carriers. When this type of denial occurs, your first step should be to check eligibility and determine which of their insurances is their primary one. Then you’ll know better how to submit the claim to the correct insurer.

Legion Health Care Solutions has a team of expert billers who scrub the claims clean and free them from errors before submitting them. Our coders are well-versed in CPT® and ICD-10 coding, billing with code modifiers, electronic data interchange (EDI) processes, industry standards, and maintaining 100% HIPAA compliance. Decreasing claim denials helps your practice in delivering a consistent and positive cash flow. Please get in touch with us in case of any medical billing assistance on 727-475-1834 or email info@legionhealthcaresolutions.com