What are some potential reasons for a healthcare facility’s insurance claims to be rejected?

According to the Medical Billing Advocates of America, about 1 in 7 insurance claims is denied across the healthcare industry. Here are some of the most common reasons:

Inaccurate patient information. This includes name misspellings, incorrect birthdays, and other inaccuracies in patient demographics.

Duplicate claims. This can occur when billing systems do not identify duplicate claims for the same procedure or service before submitting a claim.

Claim filing delays. Submitting claims after a payer’s specified timeframes can cause denials, so make sure to always review your payer’s guidelines and stay on top of any policy change.

Disproved medical necessity. If a payer deems a procedure or service as not medically necessary, they can easily reject a claim. All healthcare staff should practice detailed documentation to justify the reasons for rendering the said service.

Coding errors. Incorrect modifiers, incorrect procedure codes, and incorrect or insufficient diagnosis codes can cause claim denials. This is why it’s important to work with a healthcare billing company like HBSI that is trained and well-versed in various coding guidelines.