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Top 5 reasons for medical claim denials (and how to fix them)

October 6, 2018

eMEDIX Reimbursement Solutions allows providers to process claims in real time, delivering one of the fastest turnaround times in the industry.

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Nothing throws a wrench in your revenue cycle quite like a growing list of claim denials. For your office, denials mean less money in the door, more work for your staff, and less consistency in your monthly AR.

The good news if you are struggling with claim denials is that the most frequent causes for those denials are surprisingly easy to correct. Here are the top five most common reasons for claim denials according to Healthcare Finance, along with what you can do to fix them.

Duplicates causing medical claim denials

Healthcare Finance states that the largest percentage of claim denials come from duplicates. More specifically, they are the result of practices resubmitting claims before having received the initial response back from their insurance payers.

To minimize these occurrences, make sure to keep a firm handle on your claims inventory. Many practice management systems allow users to note activity on claims. Instruct your users to leverage these features so that everybody in the practice can see what actions others have taken. It is also important to work your claims on a regular schedule and keep your rejection queues as organized as possible.

eMEDIX Reimbursement Solutions allows providers to process claims in real time, delivering one of the fastest turnaround times in the industry.
Winner of the 2024 Best in KLAS award for ambulatory RCM services (EHR-Associated), ARIA RCM Services partners with you to build the most efficient path to a better bottom line.

Incomplete claims resulting in denials

User error affects everything, your medical claims included. According to Healthcare Finance, denials due to human error take almost twice the amount of work to correct and resubmit.

Understanding your healthcare practice’s most commonly made mistakes will help you identify and prevent these sorts of errors ahead of time. Your clearinghouse should provide you with rejections reports for precisely this purpose. Adding a front-end claim scrubbing tool and keeping to your rejections schedule are additional steps you can take.

Expired eligibility

Verifying your patient’s insurance eligibility can have tremendous benefits to your practice. Case in point: Healthcare Finance cites expired insurance eligibility as one of the top five most common reasons for denials.

Make sure you are taking advantage of the electronic eligibility tools offered through a clearinghouse like our industry-leading eMEDIX Reimbursement Solutions. Perform eligibility checks on your patients when they arrive for their appointments in addition to any checking you do when they schedule.

A surprising number of eligibility expirations occur in the time between the phone call to schedule the appointment and actual check-in. To ensure all staff is aware of a patient’s eligibility status, make sure you note the information relevant to your practice in your practice management system.

No insurance coverage can result in claim denials

There is another important piece of information that your eligibility verification will help with: a claim not being covered by the insurer.

If you adopt a real-time eligibility tool, you will be able to recognize these situations beforehand and can discuss options with your patients prior to service. When high-dollar procedures are involved, make sure you follow up with insurance carriers via phone if your electronic eligibility response does not provide you with the specifics you need.

Timely filing issues

Timely filing issues are addressed best through workflow and organization. Keep to your medical claims submission process, prioritize your high-dollar claims first, and work your rejections promptly and in an organize fashion.

If you need help managing this process, reach out to the experts on our ARIA RCM Services team and make sure you're bringing in every dollar your practice has earned.

By incorporating the tools discussed with the rest of these denial reasons, you can also minimize the chances claims are delayed at the clearinghouse level due to errors.

By checking eligibility, committing to submitting claims and working rejections promptly and regularly, and monitoring your claims rejections reports, you can minimize the impact that the top five claim denial reasons have on your practice.

CompuGroup Medical has more than two decades experience in managing and understanding best practices for revenue cycle management for independent physician practices and laboratories. We can reduce your costs while growing revenue and improving payment velocity. Contact us to set up a discovery meeting.

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