No healthcare practice wants to receive an email of their claim getting rejected. It is one of those critical components of a medical practice’s financial system that has the potential to shake the entire organization. A rejected claim means that your application filed for reimbursement does not meet the standards set by the authority. They have the potential to roadblock the cash flow in practice and while every practice hopes for and works towards getting a clean claim, negligence and manual errors often lead to claim denials.  

Before we begin with the reasons and tips to avoid claim rejections, let us first help you understand the difference between denied and rejected claim. When the information provided in the applications is wrong or improperly filled, then the insurance provider rejects the claim, it occurs prior to claim processing and mostly due to data entry error, a denial on the other hand is insurance company concluding the claim to be unplayable as it doesn’t meet the specific insurance/healthcare specialty/provider guidelines or fail to provide enough evidence for it the services to be deemed medically necessary in order for it to get paid. While a rejected application can be easily fixed by correcting the error or by providing the right details, a denied claim has to be appealed. 

Combing back to claim rejection, following are some of the common reasons why claims get rejected are:

WRONG CODING:

With the International Classification Of diseases changing every year with the evolving healthcare landscape and the growing demand for accuracy in diagnosis, it can be challenging for coders to use the right CPT code for reimbursement claim, which mostly lands them with a rejected claim. 

INELIGIBILITY:

Many times it happens that the patient doesn’t even know that their health insurance claim validity has expired. While this is a massive mistake on the part of the patient, the impact of this is bored by both the patient as well as the healthcare facility. They should have cross verified the details in the database and intimidate the patient if their non-eligibility. There is a possibility that a particular process might not be covered. 

INCORRECT PATIENT INFORMATION:

One of the most common reasons for claim denials is the inadequately filled or inaccurate patient information. Minor mistakes such as word date of birth, spelling mistake in name, wrong insurance Id can lead to claim rejection. 

SUBMITTING CLAIM TWICE:

This could be an honest mistake or a deliberate attempt at trying to get the double reimbursement. Whichever case may be, the claim ends up getting rejected by the carrier. 

NOT FILED AT THE RIGHT TIME:

If you have filed the claim after the window from the same has been closed, or if the application reached the insurance provider after the due date, then your request will get rejected. 

CODING NOT SPECIFIC:

It is mandatory for the coders to make sure that the diagnosis or the procedural coding mentioned in the claim is specific to the highest level of that particular code to avoid wrong payment for wrong diagnosis or the procedure. For example, in ICD 9- 0.0, 0.1, 0.2 were classified as benign, malignant, and specific categories of hypertension, which is 401. 

But how negligence can lead to RCM disasters, vigilance  can lead to claim getting accepted in the first go and your practice getting paid for the service they render:

  • Collect updated information on the patient from the front desk;
  • Verify patient’s eligibility status in each visit to make sure the claim gets processed quickly. 
  • Make sure the information filled in the claim is as per the updated requirement of the insurance provider. 
  • Proofread every detail from insurance ID to patient name, diagnosis code twice before submitting the claim to reduce the possibility of claim rejection. 
  • There is an excellent possibility that the patient might have multiple insurance carriers. Verify which one should the claim be filed to avoid any hassle in the future. 

So make sure that you avoid the mistakes mentioned above and follow the tips to minimize the claim rejections and maximize your profit.

A more profitable, time and cost-effective method would be to outsource billing, coding and insurance verification be it chiropractic billing service or mental health billing solutions to an adept agency, whose trained and certified coders will ensure maximum return on investment and minimum claim rejection in a cost-effective manner and in shorter turnaround time. Outsourcing also helps to save competent in house staff potential, which can be better utilized in dispensing proper treatment and care to the patients.