Avoid These 5 Mistakes for Better Claims Results

Posted on

July 12th, 2018


shutterstock_306793247 - CopyMedical coding is a complex process that varies for every procedure, patient, and insurance provider. While no billing department is immune to claim denials, they can avoid several common mistakes to reduce the frequency of them. These include:

  1. Missing information. Claims need to be as specific as possible to avoid a denial. Any missing piece of data can result in a rejection. However, the most common missing details are the date of the medical crisis, the date of onset, or the date of the accident. Avoid this mistake by examining the claim for any missing fields.
  2. Incorrect patient information. Similar to missing data, incorrect patient data can result in a claim denial. The most common examples of incorrect information include misspelled names, inaccurate date of birth, sex, insurance provider, and policy number. Double-checking the patient’s information for accuracy can avoid this kind of claim denial.
  3. Referral required. Some insurance providers require patients to receive a referral or prior authorization before receiving certain medical services. If a primary care doctor sends a patient to another physician for advanced medical tests or specialized treatment, he or she may have to issue a referral while the payer issues a prior authorization. However, receiving prior authorization doesn’t guarantee coverage. If the payer determines the services weren’t medically necessary or if the claim wasn’t filed on time, the payer may still reject it.
  4. Claim filed too late. Continuing with the above, providers must submit claims within a certain window. For Medicare patients, this is of particular importance. The Affordable Care Act reduced the claims submittal period from 15-27 months down to one calendar year. This means from the date of service (the from date on the claim), providers have one year to ensure the payer receives the claim. This means if the provider submits the claim before the end of the calendar year, but the payer receives it after the one year date, the payer can deny it.
  5. Eligibility issues. Insurance terms and coverage change often, so it’s vital to verify eligibility before receiving a service. For example, a patient may be eligible to receive physical therapy following an accident, but only for 12 weeks. If the patient meets their maximum benefit, the payer can deny any claims extending beyond that amount.

Keeping errors to a minimum is critical for successful claims management. If your claims management system is causing several errors and delays, contact the experts at Actec. Our full cycle claim and incident reporting solutions can help you close claims quickly and efficiently.