Navigating the world of healthcare insurance can often seem like a daunting task. Medical bills from doctors, hospitals, and other providers are rarely straightforward, and understanding why certain claims might get denied can be an uphill battle for those who need more expertise in this area.
But some common mistakes could result in denial. Here are four reasons medical claims get denied, so you’re better informed about how to handle them appropriately.
1. Lack of Documentation
One of the leading reasons for medical claims to be denied is the lack of documentation provided by the patient. Insurance providers must see proof that services were received and paid for correctly to get reimbursement or coverage. The claim can be rejected completely when patients fail to provide accurate information or receipt details.
It’s important to remember that even if the doctor’s office sends along all the relevant paperwork, it may be up to the patient to ensure that accurate invoices and adequate proof of payment are sent along with any insurance claims. Without this information, a claim could be denied, resulting in bad debt or out-of-pocket payments for services rendered.
2. Incorrect Code
Medical billing specialists must input medical codes when submitting a claim, which are used to describe the services a provider provides. If even one character in the code is incorrect or omitted, it can cause a denial or delay of reimbursement. This incorrect coding could be caused by an error from the specialist, a lack of training to properly identify the codes, or too much haste to get the claim in an accurate but timely manner.
To avoid this issue, medical billing specialists should check their work for accuracy and consult with doctors to confirm that proper codes have been selected before sending insurance companies any claims.
3. Not Covered by Insurance
Insurers may reject certain claims because they are not part of a policyholder’s coverage. As such, being mindful of what types of claims can be submitted to an insurer is important in ensuring greater success when avoiding the denial process. However, it’s common to face a medical denial due to inadvertently proposing out-of-network care, so having denial management for hospitals is vital in case of a medical denial.
4. Claim Filed Late
A frequent cause for denied medical claims is filing them past the insurer’s deadline. Too often, providers and their staff are overwhelmed with the paperwork in filing medical claims, which can lead to them filing after the due date has passed. This puts insurers and providers at a disadvantage; insurers may not receive payment on time, and providers may not be able to collect for services rendered.
While it takes a fair amount of effort to keep claims current, providers must double-check that they are meeting all deadlines to maintain favorable relationships with insurance companies and secure payments for services provided.
Filing a medical claim doesn’t guarantee payment from an insurance company. After submitting an insurance claim, it is sometimes denied for various reasons. Though there are many possible causes for an insurer to deny a claim, some common scenarios might include a lack of documentation to support the service provided, use of incorrect billing codes, services not covered under the patient’s insurance plan, and claims filed beyond their specified window.
Understanding these various factors can help medical providers anticipate hurdles with filing claims and work to avoid them in the future to ensure smoother reimbursement processes.