5 Weird Reasons That Claims May Be Denied

The Centers for Medicare and Medicaid Services estimates that 20 percent of claims are denied by payers the first time they’re submitted.

Since only 35 percent of providers appeal denied claims, chances are most of your denied claims end up unpaid altogether. That’s all the more reason to make sure your claims are paid the first time they’re submitted.

The most common reasons for denials – illegibility and missing information among them – result from simple neglect. With a little foresight and a viable eligibility-checking system in place, you can get nearly all of your claims through to remittance… most of the time.

What you need to watch out for, though, are those pesky, unexpected or unusual denial causes you only see on an EOB once or twice a year. These factors may be infrequent, but if they show up for a high-code procedure, they can hurt you – badly.

1. The Authorization Timed Out
The procedure was pre-authorized, but you waited too long to schedule the service. Especially for certain therapies, the window of authorization can close in as little as thirty days. Be cautious of your deadlines and submit claims right away to dodge this denial. 

2. No Referral on File
If you’re a specialist, it may be necessary for your patients to acquire referrals from their primary care doctors before visiting your office – no surprise there. But the documentation you must provide tends to differ from plan to plan, and some are sticklers for the paperwork. No matter how sure you are that you won’t end up needing them, make sure all referrals are documented in your patients’ records.

3. Bit by COBRA
Patients who are out of work and thus relying on the government’s COBRA plan for insurance are required to pay their entire policy principle every month in order to maintain healthcare coverage. Should they miss a few payments, your claim for their treatment may be rejected.

4. Lack of Progress
If a patient receiving long-term treatment but has made minimal progress toward recovery, Medicare may deny continuance of their care. This denial, in particular, is usually ripe to be appealed (and overturned) should you have documented evidence of improved outcomes.

5. Out-of-State Insurance Plans
Most payers set straightforward in-network and out-of-network reimbursement arrangements, but some outlined to only cover care in a specific state or regional area. Check insurance cards and verify eligibility very closely to keep this denial from happening to you – and your patients.

What’s the strangest denial reason you’ve ever encountered?

Free e-book:

Pros and Cons of In-house vs. Outsourced Medical Billing

Download Now!

Start typing and press Enter to search