The 5 Most Common Mistakes Causing Claim Denials

The Medical Group Management Association (MGMA) found that better-performing medical groups average just a 4% claims denial rate.

Is your practice’s denial rate above four percent? If it is, you probably need to stop blaming your payers for those denials and start looking inward at your office’s processes.

Manual errors, input oversights and timing issues could be causing more denials than you realize. Keep an eye on these common reasons for insurance denials to see if you can tighten up your billing approach and lower your rate of denials.

Claim is Illegible
Even if most of your payers are accepting electronic claims, a few them are probably still clinging to paper and requiring manual submissions. If you’ve been focusing primarily on your electronic claims, those paper forms may not be getting enough attention.

It’s common for printed claims to be messy and illegible, which is problematic for payers who scan them into their systems upon receipt.

Make sure your billers always look over claims and ensure their readability before sending them off. The MGMA recommends making sure that the printer is lined up properly with the claim form.

Claim is Not Specific Enough
It can’t be said enough: Coding to the highest level of specificity is the best way to reduce denials.

A diagnosis must be coded to the absolute highest level for that code, meaning the maximum number of digits for the code being used. You may have a four-digit diagnosis code that needs to be five digits to be accepted. Send off four and you may get back a denial.

Facilitate a dialogue between your billers and coders. Some billers are only minimally educated on coding, so make sure your billers know what truncated codes look like so they can catch them prior to claim submission.

Claim is Missing Information
If your staffers leave certain encounter data out of a claim, it could come back to haunt you in the form of an insurance denial.

A detail-oriented payer will notice omissions and count such errors as reason enough to deny a claim. The Ohio State Medical Association listed the most common pieces of missing information to be important date specifics: date of accident, date of medical emergency and date of onset.

Make sure your employees fill in all required areas on your claim forms. Have your billers double check commonly missed fields, like those above and the patient subscriber number, and make sure such errors are rectified before your claims are transmitted.

Claim is Not up to Payer Standards
Some of your payers may be more sensitive to the claim issues listed above than others. And though every claim should be perfect when it’s shipped off, knowing which payers are pickiest helps you send those insurers the most flawless claims possible.

Group your transactions by payer. That allows you to categorize and pinpoint which insurers are consistently denying claims for reasons like those previously listed. Then make certain the claims you submit to your most finicky trading partners are as clear and precise as possible.

Claim is Not Filed on Time
Timely filing denials are probably the most frustrating kind. But since every payer operates on its own filing deadline schedule, it can be easy to miss a timing window if you’re not being careful.

Have your billers keep a list of general payer deadlines handy. When possible, track and document each payer’s receipt of claim submissions.

Sometimes claims are unfairly denied for timely filing, like when a claim was submitted properly but not received by the insurance carrier within the window. Hold payers accountable for their timely receipt of your transactions.

Claim was Denied… Now What?
Appeal! The MGMA found that only 35% of providers appeal denied claims. Since payers frequently make mistakes and deny claims in error, that percentage should be much higher.

Inspect every single denied claim to make sure it’s correct and develop a denial management system in your practice. Task an employee with appeal duties.

Otherwise, you’re just allowing over 4% of the money you’re owed to slip through the cracks.

What’s your practice’s claims denial rate?