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Five Common Denials Halting Payments to Your Medical Practice


By reviewing the denials your practice receives from insurance companies, you can tailor your training and internal procedures to remedy a majority of these.

What if I told you that over 70 percent of the denials you receive from insurance companies can be prevented? Seem a little extreme? It's not. In fact, most all denials from the insurance company come from claims going out that were either not checked for completeness, correct information, or patient eligibility. You can prevent all of this with a few tweaks in your front- and back-office areas.

Do you know why insurance companies deny your claims? This is an area for you to review on an annual basis and check to see how much better you've done than the previous year after implementing a few new policies and procedures. Here are some of the major reasons:

Patient not eligible at time of service. This most often means that your front-/back-office staff did not obtain quality insurance verification prior to the patient coming in for a visit. It typically is due to the fact that the insurance had termed before you even saw the patient. In instances like this, you can bill the patient since they (hopefully) signed paperwork stating they are fiscally responsible for their bill. Whether or not they actually pay it, is a whole other blog posting.

No Authorization. This also means that when verifying the insurance prior to the patients arrival, your staff did not obtain the correct (or any) authorization for the visit. It could also mean that the initial authorization was obtained, but any follow-up visits were not. You might want to check your software program to see if there are some limitations you can place to ensure a patient cannot be seen and schedule an appointment without the correct authorization.

Benefits Exhausted. This means that when obtaining the eligibility and benefits, that dollar limits were not asked about and obtained. Insurance companies have cap amounts on some treatments and procedures. Know those before you perform them, and find out: if they have already been used within the benefit year/lifetime; if there are any pre-existing condition clauses, and/or; if the insurance is for a calendar (January 1 – December 31) year or benefit year (October 1 – September 30 for example).

Coordination of Benefits. Is the patient giving you all of their insurance information, or are they withholding one because of, say, a high deductible that they do not want to pay? It is not up to the patient to make these decisions. The insurance companies know if they are not required to pay because there is another form of payment available.

Need Chart Notes. This is one that your front-/back-office staff cannot control. This is simply the insurance company looking for the specific reason for the visit, treatment, or procedure. Utilizing your EHR system to its maximum will ensure that you do not end up with this reason for denial.

Overall, you have much more control over being paid than you think. Work closely with your front- and back-office staff, as well as billing department to identify where the denials are coming from. Then create the appropriate policies and procedures within your practice which will make sure these types of denials decrease today!

Find out more about P.J. Cloud-Moulds and our other Practice Notes bloggers.

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