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How a Medical Practice Can Fight Claims Denials

April 19, 2018

Claim Denials

There’s probably nothing quite as frustrating for your medical practice than dealing with claims denials. Bringing in a good profit is essential if your practice is going to grow and thrive. Continually dealing with denials leaves your staff spending more time dealing with denials, taking their time away from new claim submission, which slows down the revenue cycle. Here’s a closer look at some of the common reasons claims are denied, and how your medical practice can fight back at these denials. 

Top Reasons for Denials

Before looking in detail at what you can do to fight claims denials, it’s important to be aware of the top reasons claims are denied in the first place. Some of the top reasons claims get denied include: 

  • The patient didn’t meet their deductible for the year yet
  • A duplicate claim or overlapping claim was submitted
  • A benefit has been exceeded under the health plan coverage
  • The patient’s health plan coverage has ended and the patient hasn’t shown your practice proof of new health insurance
  • A coding or data error occurred with mutually exclusive codes or mismatched totals
  • There’s an inconsistent place of service marked 
  • The claim form is missing modifiers or modifiers used are invalid for the specific procedure code
  • Types or errors were made when putting in patient information 
  • The claim doesn’t include all important information or is missing prior authorization 
  • There seems to be a lack of medical necessity or a service isn’t covered under the patient’s plan 
  • Outdated current procedural terminology (CPT) codes have been used on the claim 
  • Failure to submit the claim promptly 

The Importance of a Claims Denial Audit

If your practice is dealing with a large percentage of claims denials, one of the best things you can do to fight this problem is to do a claims denial audit. You need to take an overall look at the way your practice is submitting claims. A claims denial audit can help you find recurring errors, oversights, and patterns to the denials. You’ll be able to see if denials are coming from the same company or if you’re getting denials from multiple companies. An audit will help you figure out if there’s a common mistake your staff is making repeatedly. When you answer all these questions, it makes it easier to clean up your claims denials so you get paid and get paid faster. It’s often helpful to do a claims denial audit at least once a quarter to find any ongoing issues that need to be corrected.

How to Conducting the Audit?

Conducting a claims denial audit regularly can help you start fighting claims denials. To conduct your audit, start by organizing your denials by the remark codes and the payer explanation of benefit reasons. When you look at these codes, you should get a better idea of the reason the claim was denied. Then, organized your codes into groupings based upon workflow. You could have a group for claims that have data issues, claims that need to be appealed, or a group for claims denials that are patient responsibility.

Analyze Your Results and Find the Errors

Once you’ve done the claims denial audit, you can use all this information to figure out where an error occurred, and you should be able to use that information to correct the problem in the future to reduce your number of denials. Doing claims denials audits regularly can also help you find patterns in denials that are costing your practice a lot of money so you’re able to resubmit them for payment. For example, if there’s a reoccurring issue with a specific insurance company, you may be able to find that there’s a new rule with the company that you’re unaware of causing denials, and once you’re aware of the problem, you can reduce denials significantly. 

Tips for Preventing Claims Denials 

Conducting a claims denial audit regularly is one of the best things you can do to reduce your percentage of denials. However, there are other tips your practice can use to prevent claims denials as well, including: 

  • Adequately training billing and coding staff to appropriately handle denials and deal with those rejections quickly so it doesn’t slow down your revenue cycle
  • Tracking and analyzing trends in claims denials, categorizing the denials to figure out how issues can be fixed promptly
  • Ensure staff members are up-to-date on new coding changes
  • Verify patient personal information and insurance information at every visit

Fight Claims Denials with M-Scribe 

Claims denials can be one of the toughest challenges for any physician’s practice, and they can have a negative impact on your practice’s revenue. Ignored denials quickly become costly for your practice, which is one of the main reasons many practices choose to outsource billing and coding to a professional service. M-Scribe can work with you to fight claims denials, working to ensure clean claims are submitted so you get paid the first time. Claims denials can result in thousands of dollars in lost profits, but when you work with M-Scribe, we’ll work with your practice to go beyond fighting denials – we’ll help you avoid them altogether.  Contact M-Scribe Medical Billing today to learn more about how we can help reduce your claims denials and increase your profits. 


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