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Over 200 million claims are denied every year according to the Social Security Administration

Undeniably, medical billers play extremely crucial roles in our industry. Tasked with a job that requires expert knowledge of the ever-changing regulations, accurate coding and the ability to navigate the many different claims processes of health insurance companies.  They ensure that healthcare providers and their practices are able to receive reimbursements for the services they complete. It’s so important to make sure your practice management software and medical biller are both top-notch, so that your practice is best equipped to provide services to your patients and emphasize care relationship management.

But it’s also increasingly important for medical billers to understand why claims are either rejected or denied.

Denied claims are those that are received by the insurance companies but adjudicated and denied outright.  This is often because of

  • Delayed submission
  • Submission of duplicate claims
  • Care not covered by coverage plan

Rejected claims offer better hope than denied claims, the correction process is easier for approval. This is often because of

  • Formatting errors
    • Blank fields
  • Missing/ incorrect data
    • Plan code
    • Provider IDs
    • Payer ID

According to Gina Wysor, owner and operator of Alabama-based Advanced Reimbursement Solutions, medical billers can avoid unnecessary delays and denials by paying close attention to the details.

These are some of our top six most effective tips and tricks to avoid claim rejections and denials.

  1. Submit a clean claim without errors or entries difficult to read. Double check the originating documents, such as the superbill or patient insurance card before submitting the claim.
  2. Get updated patient information each time a patient visits. Require that they fill in your form and check them for completion prior to treatment.
  3. Clearing houses don’t always catch coding errors, so double check claims when entering. Up-to-date medical billing software can help with this process, but make sure your software is compliant with current regulations.
  4. Don’t assume patients understand their Explanation of Benefits (EOB), they almost never do. Help them understand why their claims have been denied or unpaid.
  5. Routinely run reports from your practice management software to look for trends – percentages of claims denied and common reasons. Keep an eye out for insurance companies that deny frequently.
  6. Process claims reliably and quickly. Insurance payers require timely filing and will often deny them based on time limits, so make sure you submit and resolve claims promptly and accurately.

A Medical Billing Take

The first step in keeping providers and their patients happy is the prevention of claims problems, but sometimes you have to go the extra mile.  Betty Harder, owner of B. J’s Medical Billing Service, describes an all-too-common situation in which she is forced to intervene:
“One of my clients had a patient whose claim was denied due to a missing Doctor’s Provider ID. I checked the claim in our medical billing software, and sure enough, the Provider ID was there, so I called the insurance company and pointed it out to them. Three weeks later, the claim was denied again, this time due to a missing Tax ID. After I called again and pointed out that the Tax ID was there, the claim was resubmitted. Once again, the claim was denied after another delay, this time due to a missing doctor’s address which was there. Finally, I got through again and pointed out that all of the denials were incorrect and that the original claim was clean. I demanded payment plus interest for the delays. We received payment in three days.”
Despite an uphill battle for several weeks, Betty went to bat for her client and finally won. Her determination, with a little help from her medical billing software, gave her the edge. This is what really good medical billers do and why they succeed despite today’s healthcare challenges.
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Last Updated on August 16, 2022

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