Medical billing denials are the scrooge of the healthcare service industry. They have a negative impact on patients, healthcare practices, insurance companies and third party payers. Medical billing denials are not an unusual phenomenon, they affect almost all healthcare service providers of all sizes and specialities.

1. Understanding and Overcoming Medical
Billing Denials
Medical billing denials are the scrooge of the healthcare service
industry. They have a negative impact on patients, healthcare
practices, insurance companies and third party payers. Medical billing
denials are not an unusual phenomenon, they affect almost all
healthcare service providers of all sizes and specialities.
From incorrect capture of patient details to coding errors and policy
violations, there are several reasons for denials. And while medical
billing denials can be resolved, they lead to delays, extra work and in
some cases, revenue loss.
Fortunately, there are ways to deal with medical billing denials,
reduce denial rates for your practice and ensure your practice receives
payments on time.
In this article, we’ll delve into the world of medical billing denials,
their impact, and what steps healthcare practices can combat this
common but frustrating issue.
What Are Medical Billing Denials?
A medical billing denial occurs when a payer, such as an insurance
company or third party payer, rejects or denies a payment claim raised
by a healthcare practice. The denial may be for the full claim, or a part
of it. And while it’s natural for some claims to be denied, frequent or
regular denials can have an adverse impact on your practice.
Fortunately, there are several ways your practice can reduce billing
denials. The first step is to understand the type of denials you’re facing
and understanding the reasons behind them. Only then can you

2. introduce checks and balances to improve your billing process and
reduce the cause of denials.
What Are The Different Types Of Medical Billing Denials?
It’s important to understand the difference between a denial and an
outright rejection of a claim. Rejections mean the entire claim is
dismissed and no amount of payment will be made at all. In case of
denials, a part of the claim is approved for payment. Healthcare
providers can face several types of denials:
1. Medical necessity denials: These occur when the insurance
company or payer of the patient deems in accordance with its
guidelines, a particular course of treatment or care provided as not
required or unnecessary for the patient. While appeals are possible,
providers have to justify the course of treatment along with providing
extensive documentation supporting their position.
2. Technical denials: Denials due to errors, omissions, mistakes in the
claim process fall under this category. It includes coding errors and
missing or incorrect patient details. Resolution involves appeals, fixing
irregularities and resubmitting the claim.
3. Policy denials: Falling foul of insurance company policies and
procedures will lead to denials. From policy lapses to authorization
requirements, resolving these can prove difficult.
Healthcare service providers may also receive non negotiable denials,
where the insurance company will not entertain any appeals to review,
or accept revised claim documentation. In such cases, it may be nearly
impossible to recover the claim.
The Impact Of Medical Billing Denials on Healthcare
Practices
Healthcare practices mustn’t take medical billing denials lightly. By
not paying adequate attention to denials, practices open themselves to

3. delayed payments that affect revenue and cash flow. Unpaid claims are
debts - they add up and affect the balance sheet of your practice.
It doesn't stop there. Claim denials lead to extra work for your staff,
which can affect their core work and even reduce morale. They also
have an adverse affect on patient experience and will compromise
patient satisfaction scores.
Delays caused by medical billing denials can lead to regulatory and
compliance concerns as well. Your practice may face financial
penalties, or worse, legal issues that may affect its very existence.
While all practices suffer denials, the manner and number of them
must be studied and solutions found. The first step is ascertaining why
these denials are taking place, and identifying any patterns or
common causes.
Reasons Behind Medical Billing Denials
Every healthcare practice faces medical billing
denials. However, the reasons behind them may
be different:
1. Poor documentation: Incomplete or inaccurate patient information
is one of the most common reasons for denials.
2. Issues with coding: Medical coding is complex, so it should come as
no surprise coding errors are a leading cause of denials.
3. Insurance policies and coverage: Insurance companies have their
own processes with claims. From policy limits to pre-authorization
requests, various hurdles can trip a claim.
4. Time barred: A complete and well drafted claim will not get a look if
submitted after the allocated time window has closed.
Fortunately, there are ways to limit medical billing denials.

4. Overcoming Medical Billing Denials
As the old saying goes, prevention is better than cure. And that’s
certainly true in the case of medical billing. By introducing systems
that prevent denials from taking place in the first place, you can regain
control of your medical billing and prevent the heartburn associated
with denails.
1. Conducting an audit: The first step to solving your billing woes is
analyzing the denials your practice has faced, and identifying the core
reasons behind them. This will also help determine if there are glaring
holes or gaps in how your practice processes medical billing.
2. Proper documentation: A patient’s personal information, their
insurance policy details and course of treatment must all be recorded
at the determined time and without mistakes. Before submitting a
claim, practices should verify whether all the information contained in
the claim is accurate and up to date.
3. Correct coding: Practices should take steps to ensure their staff is
adequately trained to allocate correct codes. By introducing checks
and balances, practices can avoid oversight.
4. Working with payers: Working closely with payers like insurance
companies, understanding their services and requirements can
alleviate such issues. Good communication and maintaining a healthy
relationship go a long way in preventing problems from cropping up.
5. Submission schedule: Practices should create processes to submit
claims promptly and well behind the deadline imposed by the payer.
This way, any last minute concerns, issues or oversight can still be
resolved and the claim submitted.
Conclusion

5. Medical billing denials are a serious concern for healthcare practices.
They impact a practice's operations, its staff, and its bottomline.
And while it’s nearly impossible to completely eliminate denials, there
are ways to control their numbers and impact. By ensuring proper
documentation processes, following medical coding practices
accurately, and working closely with insurance companies and other
payers, healthcare practices can reduce the number of denials they
have to deal with.
Balanced medical billing with limited denials help practices streamline
their revenue and cash flows, while helping with patient satisfaction.
Don’t ignore this critical aspect of your practice.
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