The Top 5 Reasons Medical Claims Are Denied

Let’s face it, receiving reimbursements is an important component in keeping your practice up and running. You need these funds to pay staff, purchase supplies, and treat patients. For these reasons and more it can be frustrating when a claim is denied. Unfortunately, denials can make up to 30% or more of a practice’s billing.

How Do I Reduce Denials?

The first step in receiving reimbursements faster is to reduce denials. In order to do this, you first need to understand why your claim was denied in the first place.

5 Reasons Claims Are Denied:

  1. Prior Authorization Was Required: At times, a claim may be denied because prior authorization from the insurance company was required. In certain cases, procedures like MRIs and CT Scans are included on the pre-authorization list. If a procedure is going to be performed and you are unclear if prior authorization is needed, it is best to go ahead and call the insurance company to confirm. It is better to gd the leg work upfront then to have the claim denied.
  2. Missing or Incorrect Information: We are all human and we all make mistakes. That is why it is important to double and triple check information on the claims. At times, a claim may be denied because it is missing information, such as a service code. However, it is also common for claims to be denied because the information was entered incorrectly, such as a birth year of 1984 being entered as 1948.
  3. Outdated Insurance Information: Updating patient records is extremely important, especially in cases such as this. Claims can be denied due to outdated insurance information, such as sending the claim to the wrong insurance company. Be sure to ask patients if they have switched jobs lately or if they have an updated insurance card to put on file. This will help ensure the claim is sent to the correct insurer.
  4. Claim Was Filed Too Late: Let’s face it, you are busy. It is not uncommon for items to slip through the cracks. However, when it comes to submitting claims, it is important to get them submitted in a timely manner. Most insurance companies have a window of time where they will accept claims. If you wait too long and miss the window, your claim is likely to be denied.
  5. Services Not Covered: When it comes to medical insurance, there can be exclusions. To safeguard against this, it is recommended to contact the patient’s insurance company prior to beginning a service. Many times patients are unsure of what their plan covers and will rely on your office to get these questions answered. Clarifying benefits will also go a long way in keeping your patient from fainting when they receive a bill for the complete service.

Reduce Denials With AMS

One surefire way to reduce denials is to work with a topnotch medical billing company, such as Applied Medical Systems (AMS). AMS utilizes a unique progressive denial prevention system that currently allows us to submit clean claims more than 95% of the time. At AMS we use front end rules and edits specific to providers and payors to get the claim paid the first time.

When you chose to work with AMS, denials are greatly reduced. However, In the case that a denial is received, we utilize a paperless denial queue that allows us to resolve denials more efficiently, effectively, and faster. Once a denial occurs, we write a rule or edit so we don’t get that same denial again.

Learn More

If you are ready to get paid faster, we invite you to learn more about AMS. We have been providing useful services and solutions to the medical community for over 30 years. Request a free quote today.