Denied claims are altogether a different issue. Denied claims are defined as claims that were received and processed (adjudicated) by the payer and a negative determination was made. This type of claim cannot just be resubmitted. It must be researched in order to determine why the claim was denied so that you can write an appropriate appeal or reconsideration request.
Why Are Claims Being Denied?
According to the American Medical Association’s National Health Insurer Report Card (NHIEC), that provides metrics on the timeliness, transparency and accuracy of claims processing of insurance companies, there are 5 major reasons for denied medical claims:
- Missing information- examples include even one field left blank, missing modifiers, wrong plan codes, incorrect or missing social security number
- Duplicate claim for service- when claims are submitted more than once for the same service provided, same beneficiary, same date, same provider, and single encounter
- Service is already adjudicated- (unbundling) services. Benefits for a service are included within another service or procedure
- Services not covered by payer- before providing services, check details of eligibility or call payer to determine coverage requirements
- Limit for filing has expired- there are a set number of days following service for claim to be reported to the payer. If outside of that time period, the claim will be denied. Included in this period is time to rework rejections
How to Improve Claim Rejections and Denial Rates
Whether your practice manages its medical billing and coding in-house or outsources it to a medical billing company, there are steps that should be taken to manage denials:outsources it to a medical billing company
- Management must track and analyze trends in payer denials and rejections. Categorize these denials and rejections and work on how to fix these issues as quickly as possibly
- Staff education is imperative. Train billing staff to handle rejections quickly and provide training on how to appropriately handle denials
- Schedule routine chart audits for data and documentation quality to identify problems and trends before claims are sent to the payer
- Work with payers to discuss, revise or eliminate contract requirements that lead to denials that are overturned on appeal
- Utilize automated software or external vendors to optimize claim management and perform predictive analysis to flag potential denials- addressing before claims are submitted. A good clearinghouse will allow you to quickly resolve rejections plus provides a great tracking tool
Stay current on billing and coding trends and educate yourself and your staff to optimize your claim reimbursement.