There are many factors that drive the increase of claim denials in the Healthcare sector. Whether the provider or payer is at fault, it is understandable that denials occur because of how complex the medical coding and billing system is. Providers must work closely with their in-house or outsourced medical coding professionals to ensure patient information is documented accurately and medical claims are filed on time.
Poor management of processing medical claims can negatively impact a facility’s medical revenue cycle. aJust Solutions has a team of professional Patient’s advocates that can provide help in solving medical bills issues and to reduce medical facilities burden. It is their task to help streamline a positive patient medical experience through providing help with their medical bills and denied claims. Below are six of the common reasons medical claim denial issues may arise at your medical facility.
1. Medical claims are not filed on time
Every medical claim is given a specific amount of time to be submitted and considered for payment. Neglecting to submit a medical claim before its due date often results in a medical practice paying for it at their own expense. Most of the time, medical providers may miss filing medical claims on time due to incomplete or lost superbills, also known as charge tickets or an itemized list of patient services. Even when medical claims are corrected, they can be denied when submitted after their filing date has passed.
2. Inaccurate
Insurance ID number on the medical claim
It is the provider’s responsibility to verify a patient’s current ID upon each visit, which includes current changes to medical insurance. Old insurance cards and ID numbers submitted on an original medical claim may not be recognized by an insurance company or payer. Entering information manually can also result in medical coding and billing mistakes, especially if staff members aren’t trained with the proper data entry techniques.
3. Non-covered
services
According to payer policy, a service may not be considered medically necessary due to the diagnosis submitted on the medical claim. Even though a patient was given a treatment based on the medical provider’s documentation, the actual diagnosis may not have been communicated to the staff members in charge of the facility’s medical coding and billing management system. While instilling more information about a provider’s services and linked diagnoses, it can still be a challenge preventing coding and billing faults with regards to imprecise documentation.
4. Services are
reported separately
There are some procedures that should not be coded or billed together because they are either performed by a single physician or a team. It is also significant to note that physicians may belong to a practice that’s not covered by a patient’s insurance, which is why certain health services should not be piled together. A professional medical coding and billing provider will help reduce medical claim denials and the need for coding edits by familiarizing themselves with the services provided for the patient and the bundling policy of the medical facility.
5. Improper
modifier use
Common modifiers, such as modifiers 25 and 59, are used to indicate whether a service or process took place within the same day or on separate days. For instance, modifier 25 stands for an appraisal and organization (E/M) service that was provided on the same day as another service while modifier 59 represents the procedures that took place on different days. Modifier 59 also includes whether the service catered to a different organ, another provider, and doesn’t blend into the typical routine of the original service. In cases where modifiers are used inaccurately, denials are likely to happen. With the assistance of skilled medical coding and billing experts, medical denials can be reduced tremendously by applying the essential common modifiers to the proper service or procedure.
6. Inconsistent
data
When data is incorrectly entered on a medical claim, it often results in a denial of the services and procedures provided. A couple of reasons why data discrepancies may happen include an error of
gender-specific conditions being documented wrong or imprecise entry of data. It is suggested that practices make use of alert systems whenever an error or inconsistency happens. If an alert system is implemented, the error will keep the denial medical claim from being processed and not denied, which will save providers more time and money.
