Medical billing is a job of processing many details at once and no matter how good the biller is, there will still be rejected claims every so often. Wondering why your medical bill claim got turned down? Here are some common reasons why medical billing claims are rejected.
Reason #1: The claim was not filed on time.
Generally speaking, insurance companies allow 60 to 90 days from the time of service to file a claim. If it’s filed after that, it is often rejected.
Reason #2: The claim was lost, then expired.
If the insurance company lost the claim, it won’t make it into their system before the deadline and for this reason, it may be turned down.
Reason #3: Codes are missing.
If procedure or diagnostic codes are missing, incomplete, invalid, or do not line up with what treatment the physician provided to the patient, the claim may be denied.
Reason #4: There was no referral from a doctor.
Depending on what insurance plan the patient has, there may be a referral needed from the patient’s primary care provider before services can be solidified. If there are services provided before a referral is given, the insurance claim will likely be rejected.
Reason #5: Services were not completed at the right location.
Certain doctors are set up with specific insurance companies and many of them may have multiple addresses that they see patients at. It’s important to be sure that providers list the various places they serve patients that are registered with the insurance companies that they do business this. If a doctor provides patient services at a location that is not registered with the insurance company, the claim could be denied.
Reason #6: The insurance plan is from out-of-state.
If the patient’s insurance plan is from another state, it’s possible that the reimbursement plan is less and in some cases, the claim could be denied completely.
Reason #7: The doctor is not a part of the patient’s insurance company plan.
If a patient goes to a specific doctor that is not part of their insurance company’s plan, there may be a problem when it comes to filing a claim. Be sure to check to see that the provider is a paneled provider with the patient’s insurance before filing the claim.
Reason #8: More than one service is performed in one day.
Most insurance companies have a “one service per day” rule and that means that even if the patient has been cleared to have 10 sessions of a specific treatment, they can’t have two of those treatments in one day.
Guide: Accountable Care Organizations
Click here to download our Guide: "How Independent Practices Can Succeed in a Healthcare Industry Shaped by ACO Programs". If you would like more information you can Request a consultation.