Avoiding Denials and Rejections in a Physcian Practice/Clinic/Facility

 Why Your Insurance Claims are Being Denied

Medical billing is a frustrating process for practioners who are often juggling too many business tasks, as well as trying to provide excellent clinical care. In fact, many medical offices  collect less than 85% of the monies that they’re rightly owed from insurance companies. However, with good planning, and a smart billing staff , your practice can reasonably expect to collect between 96-99% of claims.

Look out for these pitfalls! There are many reasons that claims can go unpaid, including but not limited too:

Waited too Long to File the Claim

The vast majority of insurance companies allow 90 days from the time of service to file a claim. However, some insurance companies allow only 30 days to file (and a very few, such as Medicare, allow a year).

When claims are filed too long after the date of service, they are rejected.

The Insurance Company Lost the Claim, and then the Claim Expired

Sometimes insurance companies misplace claims. If a misplaced claim doesn’t make it into the insurance company’s system before the deadline, the claim will be denied. Frustrated providers might find themselves talking to someone from the insurance company who says, “even though the error might have been on our end, there’s nothing we can do. The timeframe for filing has expired.”

 Lacked Preauthorization / Authorization

Preauthorization is a must for many insurance plans. Provide services without the proper authorization, and the claim will be rejected.

Referral from a Physician

Some insurance plans require not just authorization, but a referral from the patient’s primary care provider (PCP) before services can be rendered. Provide services before a referral is confirmed by the insurance company, and the claim will be denied.

Provideding Two Services in One Day

With behavioral health, insurance companies have a strict “one service per day” policy. This means that even if a patient is authorized for 12 sessions of therapy, if you provide two sessions in one day, you won’t be paid for the second session. Clinicians who provide group therapy, psychological testing, or medication reviews beware—sometimes these services also fall under the one service per day policy.

Authorized Sessions Ran Out

When authorization is granted, it is for a limited number of services / appointments. Lose track of how many appointments were approved for, or how many sessions you have provided, and you might find that you’ve provided sessions you won’t get paid for.

The Authorization Timed Out

In addition to authorizations being for a specific number of sessions, they are also for a specific duration of time. Sometimes the timeframe is as short as 30 days. Provide services after the authorization expires, and your claim will be denied.

The Patient Changed His or Her Insurance Plan

If a patient changes his or her insurance plan, you will need to (a) be a provider networked in the new plan, and (b) get new preauthorization to see the patient / client. Fail to do either of these actions prior to providing services, and your claim will be denied.

 Lost His or Her Insurance Coverage

If a patient loses his or her insurance coverage, your claim will be denied. This is not always evident, as some patients don’t know that they have lost their benefits, or may fail to inform you.

Late to payment made for Their COBRA

COBRA is a government program where individuals can keep their health insurance after losing their job. However, those individuals need to pay 100 percent of the policy principle (a lot of money for someone out of work!). If a patient is behind on their COBRA payments, your claim could be denied.

Claim was sent to the Wrong Managing Company

Insurance companies often delegate the management of some of their plans, or some services within plans (such as behavioral health) to other companies. Fail to realize this, and send a claim to anyone other that the managing company, and your claim could be denied.

The Provider isn’t Paneled with the Insurance Company

If a provider sees a patient, but isn’t a paneled provider with the patient’s insurance company, the claim will be denied. This sounds like common sense, but with insurance companies merging, and having multiple panels within a single company (e.g., HMO, PPO, etc.), this happens somewhat frequently. Also, if a provider was working for a larger clinic, he (or she) might think that he is a paneled provider, when really he was working under his old employer’s contract with the insurance company.

Services Were Rendered at the Wrong Location

When a Practioner is paneled with an insurance company, they list one (or multiple) practice addresses. It is important to make sure that providers have all the places they serve patients registered with all the insurance companies they work with. Provide services at an unregistered location, and the claim could be denied.

The Client’s Out-of-network Benefits Differ from In-network Benefits

Out-of-network benefits often differ from in-network benefits. For example, with out-of-network benefits, insurance companies often place a greater amount of the payment responsibility on the patient, including the potential for additional deductibles that need to be met. Fail to identify the actual amount owed by the patient for out-of-network services, and you may never receive payment for your work.

The Patient has an Out-of-State Insurance Plan

If your patient has an out-of -state insurance plan, even if the company is a company that you are networked with, you might find that your reimbursement rate is less, and (depending on the patient’s specific plan) your claims can even be denied.

The Patient Has an Unmet Deductible

Even if the patient’s insurance card says that their co-pay is $10, if he or she has not met their deductible, you might receive $0 from the insurance company when you file your claim. In addition, be on high alert in January, when deductibles often reset!

Incorrect patient's information (insurance ID# , date of birth) I

If you are submitting electronic claims, AVOID entering patient's insurance number with characters like an asterisk (*) and dash (-) in between the alphanumeric numbers because these characters can be recognize by electronic as unrecognizable. Just check on this issue with the clearinghouse or your service provider. Always make a copy of your patient's primary & secondary insurance card on file (copy front and back!). Make sure to get a copy of their new card (if there is a change).

CPT/ICD9 Coding Issues (requires 5th digit, outdated codes)--- be carefulalso with your secondary code! Claims may be denied even if the problem was just because of the secondary CPT/ICD9 code!

Again as I previously pointed out with my other articles on tracking your claims, with this problem, discuss solving the coding error rather than how much you want to get reimbursed. Most of the insurance companies will help you with codes (in fairness!!) and they also inform you on outdated codes, or codes that requires a 5th digit. Be nice with the claims department! (at least you try!)

Patient's non-coverage or terminated coverage at the time of service may also be the reason of denial

That is why, it is very important that you check on your patient's benefits and eligibility before see the patient (unfortunately, I have seen practices who does not check on benefits and eligibility on their patients so they end being not paid for the service they rendered to the patient)

The patient has other primary insurance or the patient's claim is for workman's comp or auto accident claim.  

 It is the responsibility of your front desk staff to get all the necessary information before the patient can be seen. Remember that if this is a workman's comp or an auto accident claim, you need a claim number and the adjustor's name. Services are always preauthorized!

Untimely filingUnfortunately most of the insurances does not accept your billing records on your office computer that shows that date(s) you billed the insurance! They want a receipt from your electronic receipt or for postal mail, obviously they want a receipt too! a tracking number maybe? certified letter receipt? If you are submitting claims by electronic, make sure you generate transmission reports/receipts. Your reports must read "accepted" and not "rejected". File all these transmittal reports/ and receipts and a very safe place! If you are sending claims by paper or postal mail, it is a good idea to send your claims as certified mail with tracking number, keep your receipts!!