There are lots of reasons for claim denials, but most can be easily prevented.  Here are a few simple steps that are imperative to reduce claim denials.

Problem: Clerical Errors

This is the number one reason that we believe claims are denied in the typical medical practice.  Some potential problems: the name is spelled wrong or otherwise does not match the patient’s name with the insurance company, the date of birth is incorrect, or the ID number is entered incorrectly.  Solution: double-check your data entry, either as you go or on a second pass.  If you type an ID number on a carrier’s website, it’s easier and more reliable to copy and paste that number into your billing software, rather than retyping the number and possibly getting it wrong.

Tech tip: to copy an ID number, use the mouse to drag across and highlight the number on the website.  Press Ctrl-C to copy the number, then click on the field where you want to number to be, then press Ctrl-V to paste the number.

Also, take a quick glance at any copy of an insurance card that you make, or fax that you receive.  If there’s a big black line down the page, guess what number it will cover up.  Make sure that you can read the tiny print of the ID number.

Problem: Patient Eligibility

In practices that have a large number of Medicare patients, you may find that people switch to a Medicare Advantage (Part C) plan, or switch between plans.  Solution: verify each patient’s eligibility at the initial visit then periodically after that.  Your EMR system may have this capability built-in, otherwise you can subscribe to an all-payer eligibility tool on sites such as Emdeon or Navinet.  You can also set up no-charge access to each insurance company’s website to look up eligibility, claims, and payments.

Problem: Coverage of the insurance plan

A procedure may be denied if it’s not covered by the particular insurance policy.  For instance, in podiatry, many plans specifically exclude coverage for the treatment of flat feet.  Solution: if any doubt, verify coverage of a procedure with the insurance company before initiating treatment.  Many carriers have online medical policies that list the diagnoses that support medical necessity for a given procedure.

Note that a zero payment on a claim from an insurance company does not necessarily equal a denial.  If a procedure is allowed by the plan, but the payable amount goes against the patient’s deductible, the provider receives zero from insurance.  The balance is then due from the patient.  Each practice should have policies regarding the billing and collection of patient balances.

Ultimately, the patient is personally responsible for payment for his or her treatment.  Insurance is only a third party that can possibly cover those expenses, but make it clear to the patient that they will owe for anything not paid by insurance.  Every office intake form has that little paragraph that states this fact, but the office staff should actually discuss this with the patient before treatment.  If a patient has specifically agreed to the cost, they may be more likely to cover that cost.

Have a billing question?  Send it to mrbill@stlmedicalbilling.com!