10 Common Reasons Medical Risks Get Rejected and Your Action Plan
1. Incorrect personal information such as insurance ID. If you’re submitting electronic claims, you should AVOID use of entering characters like a dash and an asterisk in between the insurance number because they may be termed as unrecognizable by digital devices. Check on this issue with the clearinghouse or your service provider. Always make a copy of both the front and back of your individual’s primary & secondary insurance coverage on file. Make sure that you acquire a copy of the new card if there is a change.
2. Patient’s non-coverage or discontinued coverage at the period of service might lead to claim denial too. That’s the reason it’s quite imperative that you check your patient’s eligibility and benefits before seeing the patient. Regrettably, some clinics don’t check on eligibility and benefits of their patients, and they finally end up not being compensated for the services rendered to a patient.
3. CPT/ICD9 Coding Issues (demands 5th digit, obsolete codes). Be cautious with your secondary code too. Claims could be denied even if the issue was just because of the secondary CPT/ICD9 code! Speak about talk solving the coding mistake as opposed to how much you should get reimbursed. Most of the insurance business help you with codes, and they also advise you on outdated codes or codes that require a 5th digit. Be nice to the claims department.
4. Wrong use of modifiers. Be cautious with such procedures, modifiers for Professional and technical parts, modifiers for multiple processes, postoperative period, etc.
5. No precertification obtained if needed. It’s so complicated to submit an appeal if the claim or support was non-precertified. Avoid it.
6. No referral on record if required. Note that HMOs always need a referral.
7. The patient has other primary insurance, or the individual’s claim is for workman’s comp or car accident claim! It’s the responsibility of your front desk personnel to receive all the essential information before offering services. Keep in mind that if this is a workman’s comp or an auto incident claim, you need the number of the claim and the adjustor’s name.
8. Requires notes and & documentations to support clinical requirements. A well documented medical documents is a good practice.
9. The claim needs referring physician’s info (together with UPIN of course!).
10. Untimely filing. Unfortunately, most of the insurances do not take your billing records on your office computer that shows that date you charged the insurance. They need a receipt from your electronic reception or to for postal mail, of course, they need a receipt also. If you’re submitting claims by electronic means, be sure to generate transmission reports/receipts. Your reports have to read “approved” rather than “refused”. If you’re sending claims by postal or paper mail, it’s a fantastic idea to send your claims as certified mail with tracking number, and keep your receipts.