How widespread is medical claim denial? According to the U.S. Government Accountability Office (GAO), the Department of Health and Human Services (HHS) collected data from insurers nationwide and found that the aggregate application denial rate was 19 percent in the first quarter of 2010.* That’s approximately one in five claims. Nobody wants their medical claim to be denied. Very often, claim denial is totally avoidable. Here are the 10 best ways to limit the amount of denied claims your office receives:
- Ensure all patient information is available and accurate. For example, make sure the patient’s name is spelled correctly, the date of birth matches, and there are valid subscriber and group numbers.
- Verify the patient is still covered by the insurance benefits provided before rendering services.
- Coordinate benefits to make sure you have the right primary insurance listed, confirm the eligibility of benefits and verify the insurance information is up to date.
- Contact the patient’s insurance provider to make sure the healthcare provider is a part of the policy’s network of planned participants. Also, check to be sure that the requested services are covered and that the services will not fall under a pre-existing condition clause.
- Confirm any necessary referrals from the patient’s primary physician are on file before rendering services.
- Check to see if prior authorization or pre-certification is required.
- Be certain the doctor provided complete information and proper documentation. Request necessary medical records.
- Bill the appropriate liability carrier if treatment is for an auto- or work-related accident.
- Provide complete and valid CPT and/or HCPCS codes where applicable.
- Make sure to file claims in a timely manner prior to the insurance carrier’s filing deadlines.
