5 Reasons Why Medical Claims Are Rejected (And How To Avoid It)

 Rejected medical claims can be time-consuming and costly for your practice. Understanding the key reasons why claims are rejected, implementing a proactive approach to rectifying them, and taking steps to prevent rejections from occurring are all essential tasks for any healthcare provider.

Incorrect Provider or Patient Information

One of the most common causes of rejected medical claims is incorrect patient or provider information. Incorrect spelling, incomplete addresses, and outdated information can all lead to rejections. It’s important that you verify patient and insurance details prior to submitting claims to ensure they are accurate. Additionally, ensuring records are kept up-to-date in your practice management software will help reduce any potential errors.

Unbundling of Services

Unbundling of services is another common reason why claims are rejected. Unbundling occurs when services and procedures are billed separately instead of bundled together as a single service. This can be avoided by familiarizing yourself with current coding guidelines, as well as proper billing practices for each type of procedure you are performing.

Confusing Diagnosis Coding

Incorrect diagnosis coding is another key factor leading to claims being rejected. You must submit the diagnosis codes that pertain to the specific procedure your patient is receiving. Without accurate diagnosis information, there is no way for insurance providers to process a claim. To prevent incorrect coding, always double-check the codes prior to submitting a claim and make sure it matches what was done in the office.

Lack of Documentation to Justify Charges

Medical claims are often rejected due to a lack of receipts, notes, or documents that can show justification for the services your practice is providing and billing for. To avoid this, have proper protocols and systems in place to capture patients’ medical records in real-time and ensure you have any signatures or permission forms. Additionally, always keep a copy of these records in your office just in case they’re needed later.

Unexpected Coverage Denials and Exclusions

Unexpected coverage denials and exclusions from a patient’s medical plan can be another reason for claim rejection. Make sure to use the correct code for any service you provide, as well as verify the patient’s insurance details with their health plan before you submit the claim for payment. It also helps to keep track of changes in your patients’ plans. An up-to-date payer list makes it easy to identify what services are covered under each plan, helping avoid surprises and delays in reimbursement from payers. A Billing Professional can take the reins on these responsibilities, so you can focus on providing the best patient care. It would be to your advantage to contact a professional to make sure your claims never get rejected.