Few things in the modern world are more frustrating than denied insurance claims. You’ve dotted the i’s, and you’ve crossed the t’s. You’re certain you’ve got coverage for a particular claim. And then? Denied!
Unfortunately, this is an all-too-common occurrence for physicians and medical practitioners. This is especially true when physicians have undertaken their own medical billing tasks. Medical billing can be a very frustrating task for physicians who are handling too many business issues while trying to provide excellent clinical care.
Because of this, many medical practices often fail to collect money owed to them from insurance companies.
However, with proper planning and the help of our billing services, your practice can expect to collect on virtually all of your claims.
So, let’s discuss some of the many reasons why insurance claims can be denied.
1. Your claim was filed too late.
Most insurance companies allow you to file a claim within 90 days from the time the service was provided. However, some insurance companies only allow a period of 30 days. When a claim is filed too long after the service was provided, it will be rejected. Make sure you know how long you have to file a claim, as well as how long you have to appeal the decision if your claim is denied.
2. Lack of proper authorization.
Insurance companies often require the patient to obtain preauthorization of services before treatment, especially for nonroutine services, such as hospitalizations, surgeries, and behavioral care. If you provide services without the proper authorization, the insurance coverage claim will likely be denied.
To prevent this from happening, you can obtain pre-authorization from the insurance company on the patient’s behalf. Health insurance claims for certain health insurance plans can feature a frustrating level of requirements.
MBA Medical Billing Services will stay on top of things for you, so you don’t have to worry about having to write a letter for an external review or an internal appeal. We handle the appeal and reconsideration processes for our billing clients, so they can rest easy with the knowledge that their denials are being handled properly.
We’re experts at navigating the appeals process, drafting appeals to denial letters, and knowing the ins and outs of each particular insurance company’s summary of benefits.
3. The insurance company lost the claim and it expired.
This is the most frustrating of all reasons for claim denial. Insurance companies can sometimes lose your claim. If the claim doesn’t eventually make it into their system before the expiration deadline, they will deny it — even though it was their fault.
As a doctor, you’re responsible for your patients’ medical records. Why shouldn’t your insurance company — whether it’s health insurance, auto insurance, or term life insurance — be held to the same standard? Or at the very least accept responsibility when they lose or misplace important documents.
4. Lack of medical necessity.
Necessity is largely assumed for many routine services. However, insurance companies frequently expect a demonstration of medical need for treatment by a specialist and for many office procedures and surgeries. Most health plans base medical necessity on their own list of criteria, and if the claim is deemed not unnecessary, the claim will be denied unless you can prove otherwise.
5. Coverage exclusion or exhaustion.
A majority of health insurance companies have a list of services they do not cover, such as cosmetic surgery, infertility treatment, and gastric bypass. Some plans may also have limitations on the number of services they do cover. For instance, a health plan may cover only 30 days of inpatient treatment for a given condition. When you submit a claim for benefits that are excluded or have exceeded limitations, it will be denied.
6. A pre-existing condition.
As the Department of Health & Human Services reminds us, “Under current law, health insurance companies can’t refuse to cover you or charge you more just because you have a ‘pre-existing condition’ — that is, a health problem you had before the date that new health coverage starts. These rules went into effect for plan years beginning on or after January 1, 2014.”
However, writes the HHS, “the pre-existing coverage rule does not apply to ‘grandfathered’ individual health insurance policies. A grandfathered individual health insurance policy is a policy that you bought for yourself or your family on or before March 23, 2010, that has not been changed in certain specific ways that reduce benefits or increase costs to consumers.”
Long story short: Some insurance plans retain a pre-existing condition exclusion clause. If they discover a claim has been submitted for treatment of a condition that existed before the Affordable Care Act mandate, they will reject the claim. They might even deny a claim for a separate, new illness if any other kind of pre-existing condition was not initially disclosed. This is usually because the insurance company would not have offered coverage in the first place if the patient had disclosed the pre-existing condition in the beginning.
7. Incorrect coding.
An insurance company may deny a claim because the coding was incorrect or inadequate. This can be resolved by resubmitting the claim with corrected coding.
8. Lack of progress.
If a patient’s condition requires long-term care, or they receive long-term care with little positive results, many insurance companies will deny their continued coverage. However, this can sometimes be overturned on appeal.
MBA Medical Billing Services
If your practice is struggling with insurance claim denials, let us handle your billing and claims processes so you can focus on what matters most: your patients.
With just one phone call, we can begin the process of setting up a system of checks and balances that will keep your office running smoothly.
We’ll also keep you apprised and in compliance with any and all changes that arise from the continued implementation of the Affordable Care Act.
Get in touch with MBA Medical Billing Services today to see what we can do for you.