Claim denials can put a hamper on any organization providing medical or therapy services, stressing both patients and billing professionals. This post goes over the most common reasons claims are denied, and it also provides some pointers on how to avoid denials.
Regardless of the type of service, your organization provides the most common reason for denials is not having the correct patient information or providing the most accurate codes which describe the services provided.
Incorrect Patient Information
As pointed out Joy Hicks at Very Well Health, information that does not properly identify the patient is a prominent reason for claim denials. As examples of common errors that can cripple a claim, Hicks points to misspelled names, incorrect dates of birth, and missing and/or invalid subscriber numbers and group numbers. Problems can also arise if data taken by the health care organization does not match the data on file with the health insurance carrier.
Every employee who is involved in collecting patient information needs proper training so that they complete this step calmly and accurately. This applies to any health organization, whether it be a giant hospital or a specialty clinic.
Coding problems are another type of error that can strike virtually any medical practice. Codes are standardized identifiers of procedures and services, as explained in this guide from MedicalBillingAndCoding.org. There are three major types to be aware of. Current Procedural Terminology (CPT) codes are one prominently used system. They identify procedures performed in a medical facility. Another is the Healthcare Common Procedure Coding System (HCPCS), which fills in the gaps of the CPT system. Finally, the International Classification of Diseases (ICD) codes identify diagnoses.
These codes make it possible for insurers to process medical claims. However, incorrect coding can cause major issues. Hicks advises that a practice’s medical coders need to “stay up-to-date” on codes, which may be modified from time to time to reflect new procedures and other changes. For instance, the American Medical Association maintains CPT codes and provides resources for learning how to use and interpret them.
Also writing for Very Well Health, the pediatrician Michael Bihari advises that coding problems are often revealed when a patient receives their explanation of benefits (EOB). If a patient discovers a procedure was improperly coded, it is necessary for the medical facility’s staff to help them resolve the error quickly and effectively.
Denials in Speciality Clinics
The Procedure Is Not Covered
Another widespread problem is that insurers sometimes do not cover specific procedures. For instance, at a specialty clinic, a patient may request a certain service that their insurer excludes from coverage. Before providing any service, it is important to verify if a patient’s insurance provides coverage. If their insurance plan does not cover a service, the patient should be alerted. This will help avoid surprises and bad blood between the patient, practice, and insurer.
Repeated or Untimely Claims
Duplicate claims are another way to spawn denials from insurers, per Kevin Fuller of Healthcare Finance. Fuller advises that staff should be trained to take proper steps rather than just resubmitting a claim if they do not hear back from insurance companies.
Another problem highlighted by Fuller is that sometimes, medical care providers don’t submit a claim within the required window of time. This often occurs when practices neglect to submit smaller claims in favor of focusing on larger ones. However, if a claim spends too long on the back burner, it may be denied. The eligibility window varies from carrier to carrier and policy to policy.
Denials in Schools
Because they offer health care to students through Medicaid, schools are another type of organization sometimes caught up in claim denials. Schools face certain, specific problems. Laurie Alba Havens, who is a director of private health plans for the American Speech-Language-Hearing Association, explains that Medicaid imposes strict requirements when it comes to fulfilling claims from schools and the providers who work through them.
Havens points to paperwork—which sometimes needs to be duplicated—as a common source of problems. Havens suggests using the software as much as possible because it can reduce errors and a provider’s workload. Another recommendation from Havens is “completing paperwork for all children,” regardless of their current Medicaid eligibility.
This is a way to head off errors down the road.
It is also possible for ambulance claims to face denial, as covered by Steve Johnson for ZOLL, a medical data company. This may occur because the insurer deemed ambulance transportation not medically necessary, given the patient’s circumstances. To avoid this situation, Johnson recommends ensuring that ambulance crew members are dedicated to and trained for proper documentation. This is particularly true for patient care reports (PCRs) prepared by the crew.
Johnson lists these factors as the keys to preparing sufficient PCRs:
- A PCR should provide details on the patient’s condition and a narrative of how and why interventions were performed.
- It should describe how the patient responded to each treatment.
- PCRs should cover patient information, such as their mobility and ability to assist with the stretcher transfer.
- Other vital information includes the method used for the stretcher transfer, the reason for choosing that method, and how much or little the patient was able to care for themselves.
- PCRs should not be vague or needlessly wordy. They should be comprehensive, yet not bloated.
- PCRs should not include meaningless phrases like “transported in a position of comfort,” as such phrases provide ammo for medical insurers to deny the claim.
Careful documentation will make it much easier to build a case proving that the ambulance ride was medically necessary. Like other care providers and staff, ambulance crews should receive training and reminders that ensure they properly fill out PCRs.