Claim denial translates itself into a huge amount in lost revenue for a practice. This results in a serious disruption to a practice’s revenue cycle. It can be a major headache for practices, affecting both cash flow and efficiency. It not only affects the cash flow at your practice, but it can also damage / breach the relationship you have with your patients. Even though some claim denials can be appealed successfully, it can temporarily put the status of the claim in doubt, which is something that both you and your patients would wish to avoid. But the good news is that most of these denials can be recovered or, even better, prevented from happening in the first place!
Preventing the occurrence of a claim denial before your patient leaves the practice helps your revenue cycle grow faster, which in turn, increases your practice’s profitability. And there are many factors that help drive the increasing number in claim denials at your practice. Understanding these common reasons for denials is the key to preventing them from happening altogether. The only way to curtail the rate of denials is to identify the actual and specific causes for them.
Some common reasons for such denials:
Claims not filed on time
Insurance companies have strict deadlines for filing claims, including a date by which revised claims must be submitted. The deadlines for filing claims typically vary from 90 days to one year from the date of service. This can even be as short as 15 to 30 days. Failing to submit claims within the given timeframe can lead to delayed payments or even going unpaid. Practices miss claim filing deadlines for a number of reasons, but these reasons must be identified and avoided at all costs for the healthy working of your practice’s revenue cycle. Late submission of claims can have a huge impact on your practice, disrupting its revenue flow and creating disturbances in its functioning.
Inaccurate or missing patient information and data
It is important to make sure that you have entered the correct patient information and data without omitting any required information, before submitting the claims. Mistakes and omissions can lead to claim denials. It is one of the most recurrent reasons for claim denials. Missing or inaccurate data could be anything from Social Security Numbers to plan codes, to technical errors. It is the responsibility of the practice to make sure all data entered is accurate and valid. You can even contact the patient or the insurance provider if any additional information is needed or if any data needs to be verified. Strengthening your practice’s eligibility and benefits verification is one of the keys to avoiding claim denials due to inaccurate or missing information.
Services not covered by the insurance
Not all the services you provide to your patients are covered by their insurance policies. There may be services or procedures that are not covered by the patient’s insurance for which the patient has to pay out of his / her pocket. Claim denials occur when practices fail to perform insurance verification prior to appointments to identify such exceptions in patients’ current insurance coverage plans, which results in services and treatments going unpaid. Therefore, it’s important for practices to verify the patient’s insurance coverage thoroughly prior to consultation to avoid such mistakes from happening.
Coding errors are another common cause for claim denials. Coding errors include missing codes, wrong codes, using the wrong coding system, etc. Dental insurance coding undergoes frequent changes, and most denials occur because providers do not stay up-to-date with these changes. It is important to stay updated on these changes for a better claim acceptance rate.
Lack of proper documentation
At times, claims can get denied due to a lack of proper documentation. In several instances, the insurance provider may require additional documentation to support the claims and as evidence for the necessity of the services provided. Failure to do so may result in the claim denials you submit. Therefore, collect all necessary documentation from your patients as well as from the insurance provider to minimize the chances of claims getting denied.
Many a time, practices accidentally resubmit claims 1) without giving the insurance provider enough time to respond or 2) without following up on the existing one. This leads to duplicate claims being filed for the same services, for the same dates of service. Quite naturally, this results in a claim denial. Be mindful of the fact that the same insurance provider will not accept multiple claim submissions for the same patient’s treatment by the same doctor, for the same date of service. To avoid denials due to duplicate claims, always check the status of the claim before resubmitting; do not resubmit claims when the same ones are still being processed or a partial payment has been made.
Claim denials are common in practice, but can be curbed to a great extent with proper management. An efficient denial management system with strong claims monitoring and reporting potential can help your practice reduce its claim denials and increase billing efficiency.