Top 10 Most Common Claim Denials

Author : Akhil Singhal Post Date : April 1, 2021 Total Views: 639

Denials can be a massive thorn in a practice’s side. Chasing claims and resolving denials can be a huge time suck for your billing staff. Today on the blog, we will share the top 10 most common denials for physician practices.

  • Verifying Eligibility & Benefits:
    • A patient who is either ineligible or has no or expired insurance coverage will result in a denied claim.
  • Missing or Incorrect Information:
    • The most common mistake is missing critical information when the claim is submitted, e.g., missing service code, fields left blank, wrong plan code, etc. Due to sheer negligence, sometimes we make silly mistakes, like the birth year 1957 can be written mistakenly as 1975.
  • Incorrect Patient Demographics:
    • Anything in the basic patient demographics can be wrong, ranging from a patient’s nickname instead of a full name on the file, wrong DOB, and incorrect insurance ID can straightforwardly lead to a denial.
  • Non-covered Services:
    • Often, we fail to check eligibility and do not call payers to determine the coverage requirements. The patient’s insurance policy determines what’s covered and what’s not.
  • Pre-certification and Prior Authorization:
    • At times, especially when diagnostic studies and complex procedures are performed, a pre-authorization (MRI, CT scans, etc.) or pre-certification as indicated must be obtained from the payer based on the patient’s plan, failing which would lead to denials and is one of the most common causes of denials.
  • Submitting to the wrong insurance company:
    • Having the wrong insurance on file and submission to the wrong payer will lead to immediate rejection.
  • Timely and Appeal Filing Limits:
    • It is not uncommon for things to fall through the cracks—especially when you’re busy. There is a set time window following service for a claim to be reported to the payer. If you miss the train, the claim is bound to be denied. Similar is the case with appeal filing window limits for previously denied claims.
  • Incorrect Place of Service:
    • Each place of service has a two-digit code, and it is mandatory to specify where the service was performed (IPD, OPD, nursing home, ER) to get paid accurately.
  • Duplicate Claim:
    • Either knowingly or unknowingly, resubmitting an already submitted/approved claim is bound to be rejected and can be considered fraudulent.
  • Poor Coding:
    • Correct coding is essential for claims, so using the wrong CPT code, unmatched ICD-10 code, or wrong or no modifier, etc., can cause rejection. Also, coding is continuously evolving, and it can be easy to use and outdated code.

Now that we’ve identified the biggest culprits, you know what to watch out for and where it pays to tame time to check your work. OmniMD has created a Clean Claim Checklist to Reduce Denials to help in your claims process. Click here to download!

If denials are a concern for your practice, OmniMD would be happy to help. Click here to schedule a call.

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