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5 More Reasons Claims are Denied

5 More Reasons Claims are Denied

There are the standard reasons medical claims are denied, such as putting the wrong modifier on a code or putting the diagnoses in the wrong sequence. But did you know that some reasons are not the fault of medical coding?

5 Ways Your Claim Can Be Denied

Denials can be cause by more than an inaccurate claim. Here are five examples:

  1. The patient hasn’t met their deductible, yet.  This is becoming more common as payers raise deductibles and expand donut holes.
  2. The claim was sent to the patient’s former payer.  Someone goofed; the patient has switched insurances and this hasn’t been updated in their record.
  3. Prior authorization was required.  It’s always a good idea to double check that the patient’s plan allows your provider to provide the service before you submit the claim.
  4. Services weren’t covered.  The patient’s employer’s insurance plan certificate is unique and may exclude services the employer fears will disrupt the risk pool. If two companies have the same plan, they may not be identical.
  5. The provider is out-of-network.  Patients will sometimes get confused about who to see, or they are longtime patients and don’t realize the provider is not a part of their new network.

Anticipating some of these problems requires training the front office staff to document the insurance card each visit.  Familiarity with the payer’s general coverages, its network, and covered services helps. Keep a binder or computer folder with employer or payer exceptions that staff can review quickly, and add new information when discovered.

Certified Professional Coder-Payer CPC-P

Brad Ericson
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About Has 338 Posts

Brad Ericson, MPC, CPC, COSC, is a seasoned healthcare writer and editor. He directed publishing at AAPC for nearly 12 years and worked at Ingenix for 13 years and Aetna Health Plans prior to that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City.

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