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10 Common Reasons Medical Risks Get Rejected and Your Action Plan

1. Incorrect personal information such as insurance ID. If you are submitting electronic claims, then you should avoid entering patient’s insurance number with characters such as an asterisk and dash in between because these characters might not be recognized by electronic devices. Simply check on this issue together with your service provider. Always make a copy of both sides of your individual’s main & secondary insurance on file. Make sure that you acquire a copy of the new card if there is a change.

2. Patients terminated coverage or even non-coverage in the period of service might be the reason for denial. That’s the reason it’s quite imperative that you check your patient’s eligibility and benefits before seeing the patient. Unfortunately, some practices go ahead with service provision without checking those details and wind up not paid for the services provided to the patient.

3. CPT/ICD9 Coding Issues (demands 5th digit, obsolete codes). Be careful about your secondary code also. Claims could be rejected simply due to the secondary CPT/ICD9 code! Again talk about finding a solution the coding mistake rather than how much you need to get reimbursed. Most of the insurance business help you with codes, and they also advise you on outdated codes or codes that require a 5th digit. Be nice to the claims department.

4. Incorrect use of modifiers. Be cautious with bilateral procedures, modifiers for multiple procedures, etc.

5. No precertification or preauthorization obtained if needed. It is hard to file an appeal once the claim or service was non-precertified. Avoid it.

6. No referral on record if necessary. Note that HMOs consistently needs a referral.

7. The individual has other primary insurance, or the claim is to get workman’s comp or automobile accident claim! It is the duty of your front desk personnel to receive all the necessary information before the patient could be seen. Remember that if that is a workman’s comp or an auto crash claim, you need a claim number and the adjustor’s title.

8. The claim needs documentation & notes to support medical needs. A well documented medical documents is a good practice.

9. The claim needs referring physician’s info (together with UPIN of course!).

10. Late filing. Regrettably, the majority of the insurances don’t take your billing documents on your computer that reveals that date you billed the insurance. They want a receipt for your electronic receipt or to get postal mail, clearly, they want a receipt too. If you are submitting claims by electronic means, be sure to generate transmission reports/receipts. Your reports have to read “approved” rather than “refused”. If you are Sending claims by postal or paper mail, it’s a good idea to send your certified claims complete with tracking number, and keep those receipts.

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