10 Common Reasons Medical Risks Get Rejected and Your Action Plan
1. Wrong patient’s information about insurance ID, date of birth. 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. Simply check on this problem with your clearinghouse or your support provider. Always make a copy of both sides of your individual’s main & secondary insurance on file. Make sure you make a copy of a new card too if there’s a modification.
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. Unfortunately, some practices go ahead with service provision without checking those details and wind up not paid for the services provided to the patient.
3. CPT/ICD9 Coding problems(requires 5th digit, outdated codes). Be careful about your secondary code also. Claims could be refused even when the issue was simply due to the secondary CPT/ICD9 code! Talk about solving the coding mistake as opposed to just how much you want to have 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 Most of the insurance business can help you with codes, and they also advise you on outdated codes or codes that demand the 5th digit.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 nice to the claims department.
4. Incorrect 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. Keep this from happening.
6. No referral on a document if needed. 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. Bear in mind that if that really is a workman’s comp or an automobile incident claim, you require a claim number and the adjustor’s name.
8. The claim needs documentation & notes to support medical needs. 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 them don’t accept your charging documents on your computer that shows 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 “accepted” and not “refused”. If you are Sending claims by postal or paper mail, it’s a good idea to send your certified claims complete with tracking number, and keep those receipts.