This Blog Was Originally Published By Eminence RCM

https://eminencercm.com/blogs/top-reasons-causing-medical-claims-denials

The last thing a healthcare practice wants is medical claim denials leading to significant revenue leakage. Amidst the routine flow of medical billing and coding, claim denials add a frenzy and disrupt the revenue cycle.

As a result, it becomes a serious issue that needs an understanding of healthcare billing with precise handling. Preventing medical claims denials is significant to maximize reimbursement and improve the operational flow. On the other hand, failure to deal with denials can result in additional expenses to rework the claims.  

The reason behind denials can be anything ranging from coding or documentation errors to delays in claim filing. However, healthcare providers are responsible to tackle the challenges effectively and lead to positive outcomes. 

In this blog, we will analyze various factors that contribute to claim denials and help healthcare providers navigate through them with effective strategies.  

Top Causes Of Medical Claims Denials 

Understanding what is causing claim denials is like winning half the battle. The next step will be finding effective ways to prevent denials. Before that, let’s learn the top causes of medical claims denials:

Misplaced Or Invalid Claims 

There are chances that a claim doesn't even reach the payment processing phase. This can happen if the claim gets misplaced during the submission process.  

This situation emphasizes the need to keep a check on claims and take timely follow-up after the submission. Tracking claims highlights the position of the claims and prevents them from getting denied.

Another obstacle arises when medical claims denials happen due to untimely filing and submission. Usually, insurance companies have a time limit for the submission of claims, failing to be on time automatically results in invalid claims. In the case of submission expiry, healthcare providers find it hard to reconcile the claims to revive revenue. 

In some cases, late filing is permissible but falling behind is not good for the bottom line in the long run. Prioritizing the date of submission is vital to optimize medical billing and coding. Healthcare providers can also find solutions with expert assistance from medical billing services.  

Errors And Missing Data 

One part of successful claim filing is accurate documentation and recording without missing any patient details. Even minor errors at the time of documentation can lead to inaccurate filing and further cause medical claims denials.  

The mistakes can be anything from misspelled patient names to incorrect insurance IDs. These are reflected in medical coding such as wrongful translation of CPT or ICD codes and cause imperfect medical claims. However, such errors can be corrected by the healthcare providers if they reinforce accuracy at every step.  

Healthcare providers can rely on professional medical billing coders to avoid manual errors and prevent denials. Medical billing services utilize advanced technological solutions to eliminate the scope for errors at the time of documentation.  

Missing Pre-Authorization  

Taking approval from the insurance company before rendering medical services is known as the prior authorization process. What makes this step essential is the conformity healthcare providers get about their reimbursement.  

Not taking prior authorization can also be a major reason behind claim denials. This happens because not contacting the insurance company can cause a disconnection. 

Though obtaining pre-authorization is time-consuming, it is not advisable to skip this step in the medical billing and coding process. Healthcare providers must submit complete documents and get approvals before moving to the next step.

As it can be challenging to carry out, healthcare providers can seek technological solutions to streamline the process. They can partner with experienced medical billing specialists who are well-versed with all necessary requirements.  

Absence Of Medical Necessity  

According to insurance policies, a patient is not allowed for procedures that are not medically necessary. When healthcare providers render medically unnecessary treatments, they are not entitled to revenue.  

This can be prevented with effective prior authorization and healthcare providers can avoid revenue leakage. One more factor that helps healthcare providers in dealing with such situations is staying up to date with the latest trends and standards.  

Also staying in touch with the insurance company helps in ruling out the absence of medical necessity and saves healthcare practices from medical claims denials.  

Errors In Medical Coding  

On of the most common causes of claim denials is errors in codes. These inaccuracies can be in diagnosis codes, procedure codes, or modifiers.  

Staying specific to the specialty and translating rendered services into accurate codes is essential to effective claim filing. Otherwise, healthcare providers struggle with denials and experience a downward trend in the revenue cycle

To ensure the correctness of codes, healthcare providers must pay extra attention at the time of recording and filing data. Other than that, they can also get help from knowledgeable medical billing coders. Professionals not only apply precise codes but also eliminate the scope of manual errors.  

Prevent Medical Claims Denials With Eminence RCM

Healthcare providers need a one-time solution to tackle the challenge of claim denials to improve their revenue cycle and uplift the bottom line. Partnering with professional medical billing services can not only prevent claim denials but also help in achieving other growth-related goals.  

All the healthcare providers and practices who want top-notch medical billing services must choose an appropriate outsourcing partner. As there are many options available, choosing the best is another challenge. However, Eminence RCM is the perfect medical billing partner offering a complete range of billing and coding solutions.  

Eminence RCM is a leading medical billing company in USA, ready to assist healthcare providers and practices in mitigating errors that lead to claim denials.  

We are a team of expert medical billing coders and billers, proficient in following all medical billing steps with precision. Our knowledgeable billers dedicate their time to eliminating errors and improving the revenue cycle.  

We ensure that your healthcare practice is HIPAA-compliant and up to date with necessary regulatory trends. Apart from that, we incorporate the latest technological solutions to meet the needs of your specialty.  

Partner with Eminence RCM for medical claims denials free healthcare practice!