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5 Reasons Why Your Claims Are Denying

5 Reasons Why Your Claims Are Denying

As a medical biller, your job is to make sure the provider you work for gets reimbursed fairly for the services rendered. How can you do that when your claims are being denied for all kinds of reasons? Well, should have an idea of what types of denials you are receiving and why you are receiving those denials. A claim can be denied for multiple reasons and it's up to you, the medical biller, to know the reasons for the denial and what you can do to eliminate them. Just know that you can’t get rid of every single denial and receive payment, but there are ways that you can be proactive to help eliminate some of them. First, you need to take a closer look at your denials to see the reason they are being denied. Let’s look at five of these reasons that could possibly be preventing you from getting paid on your claims:


1. Incorrect, missing, or invalid information

This is the number one reason why your claims may be getting denied. This is mainly due to typo errors or information that was omitted from the claim. It is important to double-check any patient information such as the spelling of the first, middle initial, and last name, date of birth, active insurance policy number, correct diagnosis codes/procedure codes, any modifiers, and billed amounts that are present and correct for your claims. Any piece of information that is incorrect or omitted will automatically cause a denial. Make sure you have processes or a system in place where things like this can be determined before the claim goes out for processing. Most clearinghouses have built-in software that checks or “scrubs” claims to notify you if any information may be incorrect or missing from the claim. Double-check with your clearinghouse to make sure you have this option. It may come with your software package or may cost a little extra, but it's worth having so that you can correct those errors or add the missing information to submit a clean claim to the insurance companies. 


2. Prior Authorization needed

You should know whether prior authorization is needed if you have verified and confirmed eligibility with a patient’s insurance. You can obtain this information by calling the patient’s insurance company and speaking with a representative. If you work for a provider who does not have access to the patient, unfortunately, you will not know this information up front, but you can obtain this information from the referring physician so that you can add it to your claim. Some MCO plans may require authorization for services rendered, so be sure to verify this with the patient’s insurance company so that you know ahead of time whether authorization is required or not.


3. Out of Network

If you are out of network with certain insurance companies, this could be another reason why you may be getting denials. Most insurance companies will not pay for services rendered outside the patient’s insurance network. More than likely they will hold the patient responsible. If a patient had no control over services that were rendered out of network as in lab services, the patient would probably be upset to receive a bill from a provider they’ve never even seen. Also, some patients’ plans may not have out-of-network benefits. This may cause you to have to take a loss with this claim as it's considered a non-covered service per the patient’s plan. You can always appeal the decisions of the insurance, but the majority of the time, they will deny the appeal all because you are an out-of-network provider. So what can you do to become an in-network provider? Apply or enroll with insurance plans. All insurance companies have provider enrollment options so that you can become contracted and receive payments for your services and the patient will not have to worry about whether you are in network with their plan.


4. Services not covered in the benefit plan

Be sure to know what is covered and what’s not covered under a patient’s plan. As a medical billing specialist, you can research plan policies listed on insurance websites to see what is covered under a patient’s plan and what the policies are in relation to the services that are being rendered or provided. Also, you can get this information by calling the patient’s insurance and speaking to a representative to verify if the procedure codes are valid and billable for this patient’s plan. You are sure to get an answer on whether the services are covered under the patient’s plan and if the procedure codes are valid for billing under that patient’s plan.


5. Duplicate Claims

Another major reason why your claims may be denied is because of duplicate claims. It is very important that you make sure that you are not billing out the same claim more than once on the same date of service. Make sure you review patients’ accounts for unprocessed claims and make sure the claim has not already been billed. Also, a claim can deny as a duplicate if you make a change to the claim without processing the claim as a corrected claim. Using the original claim and a resubmission code on the claim form will notify the insurance company that a correction was made and should not be processed as the original claim. So keep in mind that if you do not indicate that the claim you are submitting with the new changes is a corrected claim, it will deny as a duplicate.


If you are receiving these types of denials, make sure you have processes in place to help decrease your denials. Not every claim will be paid, and you will still get denials for many reasons, but be sure to look at your denial trends and figure out what steps you may be able to take to eliminate those trends to start receiving revenue for the services you are billing for. This eliminates any aged accounts over 90 days that could be resolved based on the denials mentioned above. Being proactive and making a few changes and adjustments to your process and strategies just might be what you need to decrease the number of denials you receive. So why not start making changes?