Top 7 Denials in Medical Billing and How to Prevent Them

30 January 2023
7 denials in medical billing

Medical billing can be a complex and frustrating process, with many factors that can lead to denied claims. In this blog, we will explore the top 7 denials in medical billing, including the reasons behind them and ways to prevent them.

1. Incorrect coding

One of the most common reasons for denied claims is incorrect coding. It can occur while using the wrong code to describe a service or procedure or the wrong code for the patient's diagnosis. It is important to thoroughly review all codes before submitting a claim and ensure that they accurately reflect the services provided and the patient's diagnosis to prevent incorrect coding.

2. Missing or incomplete information

Another common reason for denied claims is needing more information. It can include missing patient or provider information or details about the services provided. To ensure that all claims get included, it is essential to thoroughly review them before submitting them to ensure that all necessary information gets included.

3. Lack of prior authorization

You can cover specific procedures or services through prior authorization in most insurance plans. A claim must be submitted with prior authorization to be allowed. It is essential to check with the patient's insurance plan to determine if prior authorization is required and obtain it if necessary.

4. Non-covered services

Insurance plans often have exclusions or limitations on the services they will cover. If a claim gets submitted for a service that is not covered by the patient's insurance plan, it is likely to be denied. To prevent this denial, it is important to check with the patient's insurance plan to determine which services are covered and obtain prior authorization if necessary.

5. Duplicate claims

Sometimes claims are denied because they are duplicates of a claim that got submitted already. When a provider submits the same claim multiple times or if submitted by both provider and patient, such a denial occurs. To prevent duplicate claims, it is essential to carefully review all claims before submitting them and check for duplicates before resubmitting any denied claims.

6. Timely filing

The timely filing refers to the deadlines that insurance plans often have for submitting claims. If a claim is submitted after the deadline, it will likely gets denied. These deadlines vary by insurance plan and can range from 30 days to several months after the service is provided.

Preventing timely filing denials is vital for maintaining the financial health of the medical practice, as denied claims can result in lost revenue and increased administrative burden. After the service gets provided, it is important to submit claims as soon as possible. This can be achieved through efficient and effective billing processes, such as electronic claims submission and tracking systems.

In some cases, providers may request an extension of the timely filing deadline if there are extenuating circumstances that prevented the claim from being submitted on time. However, this is only sometimes possible and should not be relied upon as a regular practice.

7. Incorrect patient information

Incorrect patient information is a common reason for denied claims in medical billing. It can occur if the patient information provided does not match the information on file with the insurance plan. It can be due to errors in the patient's name, date of birth, or insurance coverage status.

To prevent this type of denial, it is important to verify all patient information before submitting a claim. It can be achieved through effective patient registration processes and regular updates to patient information in the practice's records.

It is also crucial for providers to stay updated on changes in a patient's insurance coverage status. This can be done through regular communication with patients, as well as through electronic insurance verification systems. By staying informed about a patient's insurance coverage, providers can help to ensure that their claims are submitted to the correct insurance plan and are more likely to be approved.

In conclusion, denials in medical billing can be a significant source of frustration and financial strain for healthcare providers and patients. Understanding the most common reasons for denials and taking steps to prevent them is essential for maintaining the financial health of a medical practice.

By following these steps, healthcare providers can help ensure that their claims are processed smoothly and that they get paid for their care. In addition, implementing a robust medical billing process and staying up to date on insurance plan requirements can help providers to avoid common pitfalls and reduce the number of denied claims. Ultimately, preventing denials in medical billing is crucial for maintaining the financial stability of a medical practice and ensuring that patients receive the care they need.

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