10 Common Reasons Medical Risks Get Rejected and Your Action Plan
1. Wrong patient’s information about insurance ID, date of birth. If you are submitting electronic claims, then you should avoid entering patient’s insurance number with characters such as an asterisk and dash in between because these characters might not be recognized by electronic devices. Simply check on this issue together with your service provider. Always make a copy of both the front and back of your individual’s primary & secondary insurance coverage on file. Ensure that you acquire a copy of the brand new card incase of any change.
2. Patient’s non-coverage or discontinued coverage at the period of service might lead to claim denial too. That is why, it’s quite crucial that you check on the patient’s benefits and eligibility before you see the individual. 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 or obsolete codes). Be careful with your secondary code. Claims could be rejected simply due to the secondary CPT/ICD9 code! Again talk about finding a solution the coding mistake rather than how much you need to get reimbursed. Most of the insurance business can help you with codes, and they also advise you on outdated codes or codes that demand the 5th digit. Be polite 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 is hard to file an appeal once the claim or service 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. The claim requires documentation & notes to support clinical necessity. A nicely documented medical documents is a fantastic practice.
9. The claim requires referring doctor’s info (using UPIN of course!).
10. Late 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 want a receipt from the electronic reception or for postal mail. If you are submitting claims by electronic means, be sure to generate transmission reports/receipts. Your reports have to read “accepted” and not “refused”. ” If you’re sending claims from paper or postal mail, it’s a good idea to send your claims as certified mail with tracking number and keep the receipts.