5 red flags for claim denials


Photo used with permission from Shutterstock.comPhoto used with permission from Shutterstock.com

Medical claim denials are a hassle and can lead to financial difficulties and yet so many of them can be easily avoided.

Brian Fugere, COO of RemitDATA, a comparative analytics provider, recently talked with Healthcare Finance News, sister publication of PhysBizTech, to identify the top five most common claims denials.

[See also: Denial management innovations accelerating]

1. Duplicate claims. Physician practices and hospitals are taking part in a common mistake which accounts for the largest percent of claim denials, said Fugere. Front office administrators are hitting resubmit after not hearing back from insurance companies, which resets the clock on the time it takes to pay a claim. Denial is inevitable in this situation. “This is a bad process some practices just ignore, but they really shouldn’t.”

2. Claim lacks information. Human error impacts most practices but nowhere is this more prevalent than in claims processing. Basic information, such as a person’s date of birth or spelling of a name, are common mistakes. “This is not a good reason to get a denial,” said Fugere. “These should definitely be examined and resubmitted. Otherwise [practices] are just leaving money on the table.”

When these claims are denied, it almost always doubles the time it takes to turn around a claim, affecting the practice as well as the patient. Claims should always be examined closely, said Fugere.

Fugere added that front-end scrubbers -- technology that pre-screens claims -- can help avoid this type of commonly made mistake.

3. Eligibility expired. Most practices verify coverage beforehand to avoid issues, but sometimes that doesn’t happen. One of the most common claim denials involving verification is when a patient’s health insurance coverage has expired and the patient and practice were unaware. Also, in a lot of cases, practices may check eligibility when an appointment is made, but between the appointment being made and the actual visit, coverage can be dropped. “They should do an eligibility check again once the patient has arrived,” said Fugere.

4. Claim not covered by insurer. Another claim denial that can be avoided with verification is when procedures are not covered by an insurer. Fugere said that practices and hospitals can easily avoid this problem by using real-time verification.

5. Time limit expired. Having the time limit expire on a claim is something that can cause a great deal of aggravation. “It makes small practice owners flip out,” said Fugere.

According to Fugere, this is the most easily avoided claim denial. “This is a really bad one,” he noted. “They basically didn't send the claim in time.” Most practices concentrate on larger claims first, which mean small money claims are put on the backburner. This causes a lot of small claims to be denied, which adds up to a lot of money.

[See also: Top unexpected denied codes by major specialty]

Photo used with permission from Shutterstock.com.