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The Top 3 Reasons Your Claims Get Denied

Denied StampThere are plenty of reasons an insurer might deny your claims, but the most common billing errors are also the simplest and easiest to correct. Here are the top 3:
1. Incorrect and/or incomplete patient identifier information (e.g., name spelled incorrectly; date of birth or soc. sec. number doesn’t match; subscriber number missing or invalid; insured group number missing or invalid)
Solution: Verify patient demographic and insurance information at EVERY visit. Ask permission to photocopy the patient’s state-issued identification (passport, drivers license, etc.) and insurance card, so that you are sure to have the proper spelling, group numbers, etc., on hand.
2. Coverage terminated
Solution: Verify insurance benefits prior to services being rendered. 
3. Services non-covered/Require prior authorization or precertification
Solution: Here again, you should contact the patient’s insurance and confirm coverage prior to services being rendered. You’ll end up with angry customers if you bill a patient for non-covered charges without making them aware that they may be responsible for the charges before their procedure.

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8 Responses to “The Top 3 Reasons Your Claims Get Denied”

  1. Stephanie Fulk says:

    In regards to Item #3, I have a question and comments. I work for a medical billing company and one of our clients is a hospital based radiology practice in VA. We’ve recently encountered an issue with VA Medicaid (DMAS) and you’ve probably guessed, no auth denials. Particularly, it’s with advanced imaging (MRI, MRA, CT, etc.) performed while the patient is in an observation stay. The radiologists are “blind providers” and depend on the hospital staff for registration and authorization services. DMAS does not require an authorization for the hospital as DRG billing allows for an observation “place of service”, if you will. Therefore, they do not obtain an authorization. The radiologists, however, billing for the professional service, do not have a “observation” place of service to bill on their claim submission. We submit the claim with a POS of outpatient or ER when applicable. The ER gets paid as DMAS doesn’t require an auth in that setting, but they DO require an auth in the outpatient hospital setting. While 99% of these patients come in through the ER, once they are placed in observation they don’t always stay in the ER. Therefore, we can’t always use an ER POS. My staff and I have spent a great amount of time appealing to DMAS and trying to obtain retro authorizations with KePro (company contracted by DMAS to do authorizations/referrals) to include going through several chains of management. KePro will not give a retro-auth unless coverage is retro-activated. The professional physicians are between a rock and a hard place. Our last and final option is to talk to the authorization department at the hospital. Is there anyone else out there with this issue that might be able to lend some advice? Thanks – Stephanie!

  2. Patricia Heldoorn says:

    I don’t think you have the pull necessary to make this change. Have you involved the radiology docs themselves in this yet? It may be fixable with a conversation, department head (Radiology) to department head (Authorizations). If not, they may need to fight this up the hospital’s hierarchy. Present them with the stark financials of how much money they’re losing over this authorization issue and make sure they understand the place of service issue involved. They will need real numbers to buttress their request since this is going to mean considerable additional work for the folks in Auths as well as a change to the current workflow around Observation. Your radiologists should also consider using your explanation of the problem. It was quite clear and concise.

  3. Susan says:

    I wonder if you could not go through the retrsepctive review process through KePro when the patient is in Observsation. Seems to me it qualifies under the definition of “urgent scans” because it is being provided the same day the member is being seen by the physician. This process gives you one business day to apply for the authorization. Is it possible for your radiologists to identify these patients and notify your office in time for this review to be requested?
    Here is what I found in the manual:
    Also, urgent scans that are performed prior to obtaining service authorization must be
    retrospectively authorized. The definition of an urgent scan is when the ordering physician
    identifies an urgent need to have a scan performed the same day as seen by the physician. The
    physician sends the patient immediately to the hospital or scanning facility to have the scan
    performed. The ordering physician or his/her representative, hospital, facility or radiologist must
    contact KePRO for retrospective authorization within one business of the scan being performed.
    When contacting KePRO to perform retrospective review, notify KePRO that Medicare Part B
    has been denied, or that the patient has retroactive eligibility, or that the scan was performed on
    an urgent basis and provide the necessary information and medical appropriateness indications
    for the scan that has already been performed.
    Physician/Practitioner Manual
    Chapter Subject
    Service Authorization Information
    Page Revision Date
    March 13, 2013

  4. Susan says:

    Also, according to the manual “observsation status” constiutes an emergency situation – does that not forgo the need for prior authroization:
    (see the 4th bullet point)
    Emergency Situations:
    • Initial treatment following a recent injury. “Recent” is defined as having
    occurred less than 48 hours prior to the visit.
    • An injury sustained over 48 hours prior to the visit and the symptoms have
    deteriorated to the point of requiring medical treatment for stabilization.
    Note: Minor injuries requiring only simple first aid that can be done in the home
    such as cleansing and bandaging an abrasion, are not considered
    emergencies. A secondary diagnosis such as Diabetes Mellitus may
    support the emergent need if substantiated.
    • Initial treatment for medical/surgical emergencies, including indications of severe
    chest pain, dyspnea, gastrointestinal hemorrhage, spontaneous abortion, loss of
    consciousness, status epilepticus, or other conditions considered “lifethreatening.”
    • Visit in which the member’s condition requires observation status or immediate
    hospital admission or transfer to another facility for further treatment or visit.
    • Motor Vehicle Accident (MVA) within 48 hours.
    • Physical abuse (suspected or confirmed) within 48 hours.
    • Epistasis requiring packing
    • Allergic reaction with airway compromise
    Chapter Subject
    Covered Services and Limitations
    Page Revision Date

  5. Rehana Husain says:

    I agree you should refer to the Payor’s Claim Manual –especially the chapter related to Ancillary services rendered in POS other than office. I also think it is a good idea to show the amount of Revenue lost to Senior Leadership due to miscommunication and poor workflow–this will cpature their attention. When it is time re-negotiate the contract with the Payor –please bring this issue to the table and see if something could be worked up at the front-end rather than at the back-end (i.e. getting retro-auths etc).
    Rehana Husain

  6. Elliot Barry says:

    I hate claim denials. It’s frustrating the physicians. Your remedies regarding the claims denials are helpful to conquer the denials. http://goo.gl/PnSZWZ

  7. Robin Peck says:

    How can I fight the denial of a professional component claim if we are not in network with an insurance? I appeal and write letters explaining we are a radiology practice only and patient had no control where their study was sent, but it does not ever do any good no matter what the insurance. We do not see the patient and at the time the radiologist reads the exam we have no clue what insurance the patient has.

  8. Onemedall says:

    There are a lots of things happen same as the #3 steps. in this case we have to be aware on the patients insurance because some of it maybe not covered or covered even if we are not responsible with it. thanks because we can have an idea when it comes on us.