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The 8 most common orthopedic denials

September 25, 2019

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Let’s jump right in to the top 8 claim denials in orthopedics. As you’ll see by the list, many are preventable. 

  1. Claims missing information:
    1. Date of accident
    2. Date of onset
  2. Timely filing
    1. Claims timeline to insurance carrier
    2. Appeals or correct claim have defined timelines
  3. Incorrect Patient information
    1. Patient name needs to be spelled correctly
    2. Date of birth needs to be accurate
    3. Patients sex needs to be accurate
    4. Correct Insurance ID number and group number
    5. Patients relationship to insured
  4. Wrong Insurance billed
    1. New policy Number
    2. 2ndary vs. Primary Insurance
  5. Date of Service
    1. Date spans
  6. Place of Service Codes
    1. Ensure the correct place of service code is used
    2. Ensure facility name and ID number are reported if different then provider’s service location.
  7. Coordination of Benefits
    1. Confirm coordination of benefits is updated with insurance carrier
  8. Preauthorization of correct CPT/procedure code with insurance carrier.
    1. Authorization is obtained prior to the procedure, if the procedure was changed the insurance carrier needs to be notified to rectify the authorization.

Looking through this list, the biggest take away is how each one is easily avoidable with a better process. If your clean claim rate is below 85%, it’s time to take a look at your revenue cycle processes. Even with the constant change in healthcare from coding guidelines to patient policy changes, many practices are still operating on the same processes that have been in place for many years. Evaluating your denials and finding the areas of opportunity that need to be addressed is critical for practices. 

What ortho denials are most common for your practice? When is the last time you reviewed your RCM processes? 

If you’re struggling with denials and AR, Coronis is here to help. Contact us for more information on our revenue cycle assessments.

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