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What Are The Top 10 Denials In Medical Billing?

Aug 15

A medical practice's most challenging part is earning sufficient revenue. Revenue helps to cover overhead expenses and provide quality care to patients. The claim denials are the biggest enemy that ruins medical practice's revenue cycle. The medical billing process is a very complex process for every practice, and it requires different sorts of services, including physician credentialing services. The main issue in this process is the denied or delayed claims resulting from coding and billing errors. Many medical practices, therefore, outsource medical billing and credentialing services from companies like U Control Billing. 

In this article, we will discuss the denials faced by podiatry practice. Though it is a peculiar field, it has its sweet billing challenges. It faces different types of denials, but a few tips and an experienced podiatry billing service provider can help prevent them! 

What Are The Types Of Medical Billing Denials?

There are two main types of claim denials: hard and soft. 

Hard denials:

It is a type of denial in which an insurance company or the payer refuses to reimburse a medical practice because the service they have provided is not covered. Appealing a hard denial to reverse or correct may also fail and lead to lost revenue. 

Soft denials:

It is that type of denial that an insurance company denies due to minor errors like missing data or lack of documentation. These denials are not permanent and can be revered upon correction or providing the required information. 

Podiatry billing service providers usually know the cause for claims denials, and that's why they use proactive strategies to prevent them.

Top Denials In Medical Billing 

Delayed and denied claims are the most annoying parts of the medical billing process of podiatry practice. Claim denial sometimes results in lost revenue and often consumes the practice's significant time to fight or recorrect the denied claim. Here are some common denials that medical practices face: 

Incorrect Patient Identifier Information

It is one of the most common errors. To keep away from such errors, ensure the name, DOB and sex of the patient are spelled accurately. In addition to the patient's information, ensure that the correct insurance payer and policy number are entered. Some other tips include

  • To check if the claim needs a group number.
  • Ensure that patient's relationship with the insured is correct.
  • The diagnosis code matches the procedure performed.
  • Ensure that the primary insurance is listed. 

Medical Coding Errors

Medical coding errors are one of the main reasons for denials and delayed claims. Common coding errors include missing codes, wrong codes, overcoding and undercoding. Some other medical coding errors occur when the wrong coding system is used for the insurer. Sometimes claims contain higher-level CPT or HCPCS codes that are not needed by the medical facts, medical necessity, or the provider's documentation.

Authorization/Pre-Certification

The rules for prior authorization requirements often get changed unexpectedly, and when these requirements are not met with the payers' needs, the claims get denied. This is why practices have to ensure that the resubmitted denied claims fulfill the updated requirements of the payers. 

Duplicate Billing

Often practices duplicate billing, which causes denials. Usually, when a medical practice switches to automatic payment services, this automation automatically generates bills. For instance, you see a patient for the sake of consultation and the bill for this, but your automatic billing software produces a fee related to a service you provided; this is known as duplicate billing, which is not paid. This billing issue is complex, so most insurers deny the claim. 

The Time Limit For Filing Has Expired.

Most payers or insurers have set a time limit for claim submission, including reworked claims and reviews to check coverage, codes and other such errors. Many studies have shown that many claims get denied because they are not filed within the time limit or sometimes resubmitted after the deadline. 

Noncovered or Excluded Charges

Insurance companies cover some procedures and exclude others. For instance, treatment for insomnia is usually excluded from the coverage. When claims are submitted for such a procedure, they get denied, so it is better to ensure that the insurance companies cover the procedures and treatments provided. Also, after the Affordable Care Act, such cases are being covered, so if a claim is denied for one of the Affordable Care Act's Essential Health Benefits, you can challenge that claim. This type of error is less common, and mostly the claims are denied because of other coding errors that can be avoided by partnering up with a good podiatry billing service provider. 

Lack Of Coordination Of Patient Benefits

There are a few patients who have more than one insurer or payer. In such cases, the claims should first be submitted to their primary insurers. Then according to the need, the balance should be divided among the secondary and tertiary payers of the patient. But sometimes, the coordination among the payers is lacking and causes claim denials. Here are some common reasons behind the lack of coordination: 

  • Another insurance is considered primary.
  • The estimate of benefits is missing.
  • The member has not updated additional insurance information.

Overlapping Claims

Whenever a service period of one claim seems to overlap, it is known as an overlapping claim. Overlapping claims differ from overlapping claims because these claim denials occur when a patient receives services from more than one provider. For instance, a patient with liver problems consults two different providers without asking for a second opinion referral may face a claim denial because both consultations overlap. If you want to challenge such denials, ensure that you can provide exact information about the reason behind the overlap. 

Medical necessity

Medical necessity is one of the top hard denials that occur because of the following reasons: 

  • Length of stay
  • Ill-suited level of care
  • Inpatient requirements have not been met
  • Unsuitable use of the emergency room

Billing the Wrong Company

Today, many patients frequently change their health insurers because insurers' rates differ; now and then, many new providers join or leave the marketplace. This is why billing claims are often sent to the wrong insurance providers. This is why a practice needs to check the insurer of the patients because it is very likely that the insurer that the patient had last year might not be his this year! 

Let Us Wrap Up! 

Denied and delayed claims can cost a podiatry practice thousands of bucks that could be used to improve the facility's staff, patient care, and other elements. A practice should, therefore, never dismiss a denial and should instead fight or challenge these denials. You do not have to fight this battle alone; outsource podiatry billing services from U Control Billing and let them help you detect and eliminate the problematic trends that result in denied or delayed claims.