7 Most Common Reasons Why Claims Get Denied

There are several reasons why several medical claims are denied these days. Policies have gotten trickier or harder to interpret, and there is the possibility of miscommunication and several other factors. These denials or lowering of the reimbursement amounts can profoundly impact the workflow, staff management, customer influx, and breach of trust and even inflict heavy losses to the company. These problems can be handled by third-party medical billing services at a considerably low cost and also prevent these from happening at all for just a few extra bucks.

Here are some common occurrences of these claims and how to prevent these medical claim denials.

  • Outdated Insurance Information

One of the most common mistakes would be providing information that is outdated and is no longer valid. This is a simple case of not understanding the full terms and conditions of service or forgetting to avail of the services within the due time. The insurance provider mentions the terms, or it is accessible in a soft copy about the validity and duration of the services they cover. It is advisable to keep in touch with the insurance agents to reduce, thereby the risks of availing services that the company does not support beyond a fixed time.

  • Missing or Incorrect Information

This factor is another primary reason for denials of a claim. This error is either the fault of the customer that provided the wrong information or the agent who put the incorrect input data while digitizing the data. This aspect could be easily prevented by double-checking the data and cross-checking before entering it in the database.

  • Authorization/ Pre-authorization required services

Some specific services require authorization or pre-authorization from agencies before availing them. For example, CT scans would require pre-authorization before being performed on the customer. Several other procedures also are necessary to be authorized. Check beforehand with the company to ensure that they cover the service and authorize it to prevent future hassles and denials. Other authorization issues involve running out of authorized sessions, timing out of authorized services, and availing duplicate services for one authorized service. Ways to reduce this problem include checking the patients’ insurance and getting in contact with the payer/service provider. It is recommended to have a third party medical billing company do this job instead of cutting all tensions of this problem.

  • Change of/in insurance plan

Any change in insurance plans is also a factor in increasing medical billing denials. If a current program offers services that a patient has access to utilize, but due to a change in insurance plan, it is no longer available, then it is mandatory to let the medical staff know about this, or it leads to unnecessary complications. There are procedures to enable the patient to change insurance plans, which reduce this problem. After buying a new insurance plan, it is essential to explain it to the medical service provider and get authorization for the required services in the future.

  • Claim requested at wrong company or location

This is a simple enough problem that could be avoided if the patient knows about the policy thoroughly. Denials to these claims are caused by availing services that operate outside the area of service providence does not make the insurance company responsible for it. It is necessary to verify the location of the service to be availed and the company that allows you to avail it in both places and cross-check that information to avoid mishaps. Denials in these cases are easy to prevent but hard to deal with as it can be confusing to deal with after it occurs. This also includes out of state transactions that cause issues like lowering the reimbursement rates and in some cases, can also be denied.

  • Services not granted and duplicate claims

The services that were not allowed to customer despite being mentioned in the plan are a cause of denial in some cases. This miscommunication error occurs between the payer and the provider. Some services may cover specific subsections of a procedure, so intricate details must be examined in the policy before availing it.

  • Claim filed too late

This is a common cause of denial. If the claim is invalid due to the authorization timing out, claim expired, or policy does not cover the date on which the service was availed, then it is possible that the claim will be denied or rejected. This dilemma can be avoided by staying in touch with the payer or ensuring this process to a third-party medical billing service provider.


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