Medical billing denials are the bane of many practice existences. Here are the most common reasons for claim denials. https://www.mgsionline.com/healthcare-denial-management.html

1. Most Common Reasons for
Medical Billing Claim Denial
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2. Introduction
 Medical billing claim denials affect
physician practice and cash flow.
 By reducing the claim denials rate, you
can enhance your practice profitability
and reduce administrative costs.

 To overcome the issue with a claim
denial, it is important to understand the
common reasons for claim denial.
 Let us discuss the most common reasons
for medical billing claim denials.

3. Incorrect Patient
Identifier Information
 Patient identifier information is the most important one to submit a
medical claim with precise patient identifier information that helps the
health insurance company to find the patient’s health insurance plan to
make payment.
 Most of the claims denied because of inaccurate patient identifier data
are:
 Incorrect subscriber or patient name
 Incorrect subscriber or Patient’s date of birth
 Incorrect subscriber numbers
 Incorrect subscriber group number
 Insurance ineligibility

4. No Referral on File
 Most of the insurance companies adopted the referral process.
If the patient has not got a referral from their primary care
physician, then the physician should not provide service.
 In such a case, the claim is submitted prior to the primary care
physician’s referral, then the claim will be denied.

5. Claim Was Filed After
Insurer’s Deadline
 If the claim is not filed before the insurer’s deadline, then it gets denied.
Be aware of timely filing deadlines (TFL). Here a few examples of
timely filing deadlines.
 United Health Care
Timely filing deadlines are mentioned in the provider’s agreement.
 Aetna
Physician: The claims must be submitted within 90 days from the date
of service.
Hospitals: The claims must be submitted within one year from the
date of service.
 Tricare
Claims must be submitted within one year from the date of service.

6. Missing or Invalid CPT
or HCPCS Codes
 For the medical claim process, the healthcare industry
uses standard codes to point out services and
procedures.
 This coding is called Current Procedural Terminology
(CPT) or Healthcare Common Procedure Coding
System (HCPCS). These codes change frequently.
 So it is important to ensure whether your medical coder
stays up to date with revised codes.

7. Lack of Documentation
to Support Necessity
If the payer is not confident of the medical necessity of the procedure, the
claim will be denied. In such a case, they may require an additional
document to adjudicate the claim. For that, medical records include the
following items:
 Patient medical history
 Patient physical reports
 Physician consultation reports
 Patient discharge summaries
 Radiology reports
 Operative reports

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