Majority of the healthcare providers in US struggle while dealing with health insurance claim denials. Getting frequent claims denial from the insurers can be quite frustrating, and can lead to major losses if proper action is not taken.

Industry Standards State

Top Reasons Health Insurers Deny Physicians’ Billed Services

Private Health Insurers % of Denied Services Medicare % of Denied Services
Non-covered Service 50.00% Non-covered Service 31.00%
Patient Not Eligible for Benefits 25.00% Claim Lacks Information 23.00%
Claim Lacks Information 9.00% Claim Sent to Wrong Health Insurer 16.00%
Prior Authorization Required 5.00% Not Medically Necessary 14.00%
Claim Sent to Wrong Health Insurer 4.00% Patient Not Eligible for Benefits 13.00%
Documentation Required 3.00% Documentation Required 1.00%

Source: National Healthcare Exchange Services 200

Moreover nearly 23% of the claims submitted by the physicians to commercial health insurers are not paid. Of these, most common reason for claims denial is patient deductibles.

Some of the common reasons leading to patient deductibles-

  • The subscriber is deemed ineligible for coverage
  • Medical coding doesn’t follow a particular procedure
  • The charge submitted is not compatible with a negotiated ratio
  • The patient is required to have precertification from the insurer (prior approval before agreeing for an MRI or a surgery)

Several claim rejects and edits can behave as a barrier to successfully getting claims into the adjudications system. Due to this, doctors have to spend hours correcting the claims and resending it to the insurance companies. According to the AMA research, doctors’ offices spend an average of 20-plus hours each week dealing with “claim edits.”

How can physicians reduce unexpected denials and rejection?

Some of the most common reasons are mentioned below, which can help you in filing correct claims and submit them successfully.

  • Ensure that the Member ID number is mentioned correctly on the file
  • Ensure that the billing number/provider tax ID is mentioned correctly on the file
  • Make sure that the claims goes to the right health insurer in a timely manner
  • Ensure that all the information needed in the claims is filled accurately
  • In case of requirement of prior authorization, make sure that it is taken beforehand
  • Ensure patient eligibility before filing the claim
  • Ensure that all the documents required are submitted along with the claim
  • Make sure that the medical necessity of the procedure has been mentioned in the claim
  • Make sure that the date of claims and the dates of service on the claim is valid
  • Make sure that the patient's name is entered without any unintentional spaces

Improve denials management with MBC’s complete billing solution!

MBC's experienced professionals can help ensure clean claim submissions through their immense experience in documentation and coding-

Complete Data Analysis To identify the denial trends not apparent in the aggregate data
Charge Overview To identify loopholes in  procedures documented and check for misplaced and missed charges
Training Assistance To facilitate basic coding skills to staff to assess medical necessity
Back-End Editing To identify claims with codes that might not support the medical necessity
Documentation improvement To address deficiencies not covered by the  clinical and coding professionals
Releasing Information To provide copies of patient information to the insurer on time when requested

All these actions help reduce denied claims and increase your practice efficiency and revenue. has been successfully helping clients improve denials management and increase revenue. MBC is the largest consortium of billers and coders providing medical billing across all 50 US States in varied specialties.

MBC constantly aims to stop inaccurate claim submissions by vigilant monitoring of claims submitted to improve accuracy, compliance and productivity.

Published By - Medical Billers and Coders
Published Date - Sep-24-2013 Back

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