Medical Claim Denied

by | Nov 8, 2016 | Blog, Medical Practice Management

Man with a look of frustration as he looks at a computer

(Updated April 20, 2021)
Medical billing requires meticulous attention to detail. And no matter how good the biller is, there will still be rejected claims. In many cases, there’s nothing wrong with the submitted claim itself, but mishandling somewhere along the line could lead to issues.

Just because a claim is initially denied doesn’t necessarily mean that isn’t truly payable. You can often obtain the appropriate payment by filing a corrected claim, submitting an appeal to the insurer, or requesting an external review. Wondering why your medical bill claim got turned down? Here are some common reasons why medical claims are rejected.

  1. The claim was not filed on time: Depending on the language in their contracts, insurance companies often allow just 60 to 90 days from the date of service to file a claim. If it’s filed after that, it is often denied due to untimely filing.
  2. The claim was lost: If the claim is lost somewhere along the way, prior to being processed, it won’t be paid or denied. Providers need to identify lost claims and make sure a replacement claim is received during the timely filing period.
  3. Codes are missing: If the procedure or diagnostic codes are missing, incomplete, invalid, or inconsistent with the circumstances, the claim may be denied.
  4. There was no referral: Depending on the requirements of the health plan, a patient may need a referral from their primary care provider in order to be treated by other providers. If a referral was needed but not obtained prior to the date of service, the claim may be denied. While some payers will allow patients to obtain a retroactive referral after being treated, many don’t.
  5. Services were not completed at the right location: Providers often see patients in a variety of settings. They provide treatment at multiple offices, hospitals, surgery centers, outpatient facilities, online, or even at a patient’s home. Many insurance companies require a comprehensive accounting of the locations where a contracted provider sees patients, and may deny the claim if the treatment wasn’t provided at one of the contracted locations.
  6. The insurance plan is from out-of-state: If the patient’s insurance plan is from another state, it’s likely that the provider is not contracted as in-network with that insurance and the claims may be processed with reduced benefits or denied entirely.
  7. The doctor is not a part of the patient’s insurance company plan: Even if the insurance company is in the same state, the provider could still be out of network for the plan, causing the claim to be denied or processed according to the patient’s out-of-network benefits. Providers should check each patient’s health insurance eligibility and benefits to verify that they are in-network prior to seeing the patient, and obtain pre-authorization when needed.
  8. Multiple procedures: There are tens of thousands of procedures (CPT) codes used to bill for services provided to patients. There is considerable overlap in the services that codes entail, so that full payment for multiple procedures on the same day would cause providers to be paid multiple times for the same activity because it’s a component of multiple procedures. For that reason, many services are considered an integral component of another procedure and may not be payable along with the other procedure. Other procedures may be paid at a lower rate to account for the overlap.

It can be stressful for patients planning an upcoming medical procedure. Having the insurance deny all or part of a claim for the services can make the ordeal even more frustrating. However, there is help if you find yourself in this situation.

Consumer Assistance Programs provide money for states to assist people needing help with their health insurance, such as appealing a medical claim denial. The Patient Advocate Foundation also works to help those with chronic health issues dealing with medical claim denials.

Get Help With Your Medical Billing

Are you finding that many of your patients are experiencing claim denials due to incorrect coding or other issues originating from within your office? Problems in the billing department reflect poorly on your practice and can end up costing you money in the long run.

You went to medical school to practice medicine, not to deal with billing paperwork. Let MBA Medical Billing streamline your processes, decrease the number of claim denials, and allow you to see more patients. When you’re free of worry about the business side of your practice, you can focus more on helping your patients.

We can train your billing department on best practices or take over that portion of the practice. We’re experienced in billing and coding, medical practice management, revenue cycling management, and bookkeeping. We can also help with IT services as well as search engine optimization (SEO) marketing efforts.

We’ve been helping health care professionals like you get their office management in order for more than a quarter of a century. The healthcare industry sees changes on an annual basis – and we pride ourselves on staying on top of those changes. Is the stress of running a business affecting your practice? Contact MBA Medical to see how we can help.