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. Check on this issue with the clearinghouse or your service provider. Always make a copy of your individual’s main & secondary insurance card on record of the front and rear side. Ensure that you acquire a copy of the brand new card incase of any change.

2. Patient lack of coverage or terminated coverage during the service period may also be a good reason for denial of a claim. That is why, it’s quite crucial that you check on the patient’s benefits and eligibility before you see the individual. 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 CPT/ICD9 Coding problems(requires 5th digit, outdated codes).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 denied even if the issue was just because of the secondary CPT/ICD9 code! Speak about talk solving the coding mistake as opposed to how much you should get 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 Most of the insurance business can help you with codes, and they also advise you on outdated codes or codes that demand the 5th digit.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 bilateral procedures, modifiers for multiple procedures, etc.

5. No precertification obtained if needed. It’s so complicated to submit an appeal if the claim or support was non-precertified. Keep this from happening.

6. No referral on record if required. HMOs always require a referral.

7. The individual has other main insurance or the patients claim is for auto accident claim or workman’s comp! Your front desk personnel should receive all the essential information before the patient can be seen. Keep in mind that if this is a workman’s comp or an auto incident claim, you need the number of the claim and the adjustor’s name.

8. Requires notes and & documentations to support clinical requirements. A well documented medical documents is a good practice.

9. Claim requires 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 want a receipt from the electronic reception or for postal mail. If you’re submitting claims by electronic means, be sure to generate transmission reports/receipts. Your reports should read “accepted” and not “rejected. ” If you’re sending claims from paper or postal mail, it’s a good idea to send your claims as certified mail with tracking number and keep the receipts.

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