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Answer Upon - 10 Common Reasons Why Medical Claims were being Denied and your Action Plan
Every self-help tape I've heard and every book I've read on how to become a success suggest finding a mentor. What is a mentor? What is a mentor's role? Where do I find one? Should I have only one mentor? In this article, I tackle some of these tough questions.What is a mentor and what is a mentor's role? I decided to look mentor up in the dictionary and found the succinct descriptions: "trusted counselor or guide," "a wise, loyal advisor," and "a teacher or coach." I feel the op
(4) Incorrect use of
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(2) Patient’s non-coverage or terminated coverage at the time of service may also be the reason of denial That is why, it is very important that you check on your patient’s benefits and eligibility before see the patient (unfortunately, I have seen practices who does not check on benefits and eligibility on their patients so they end being not paid for the service they rendered to the patient)
(3) CPT/ICD9 Coding Issues (requires 5th digit, outdated codes)--- be careful
also with your secondary code! Claims may be denied even if the problem was just because of the secondary CPT/ICD9 code! Again as I previously pointed out with my other articles on tracking your claims, with this problem, discuss solving the coding error rather than how much you want to get reimbursed. Most of the insurance companies will help you with codes (in fairness!!) and they also inform you on outdated codes, or codes that requires a 5th digit. Be nice with the claims department! (at least you try!)
(4) Incorrect use of
A National Medical Support Notice (NMSN) may be sent to you, if one of your employees has a child support obligation, by a state child support enforcement agency (CSEA). The NMSM is a standardized form that advises you when your employee has been ordered to provide health insurance coverage for a child through your company's health plan.The NMSN is a federal form that all state child support enforcement agencies must use. If an order has been issued and health coverage is available through t
(2) Patient’s non-coverage or terminated coverage at the time of service may also be the reason of denial That is why, it is very important that you check on your patient’s benefits and eligibility before see the patient (unfortunately, I have seen practices who does not check on benefits and eligibility on their patients so they end being not paid for the service they rendered to the patient)
(3) CPT/ICD9 Coding Issues (requires 5th digit, outdated codes)--- be careful
also with your secondary code! Claims may be denied even if the problem was just because of the secondary CPT/ICD9 code! Again as I previously pointed out with my other articles on tracking your claims, with this problem, discuss solving the coding error rather than how much you want to get reimbursed. Most of the insurance companies will help you with codes (in fairness!!) and they also inform you on outdated codes, or codes that requires a 5th digit. Be nice with the claims department! (at least you try!)
(4) Incorrect use of
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(3) CPT/ICD9 Coding Issues (requires 5th digit, outdated codes)--- be careful
also with your secondary code! Claims may be denied even if the problem was just because of the secondary CPT/ICD9 code! Again as I previously pointed out with my other articles on tracking your claims, with this problem, discuss solving the coding error rather than how much you want to get reimbursed. Most of the insurance companies will help you with codes (in fairness!!) and they also inform you on outdated codes, or codes that requires a 5th digit. Be nice with the claims department! (at least you try!)
(4) Incorrect use of
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(3) CPT/ICD9 Coding Issues (requires 5th digit, outdated codes)--- be careful
also with your secondary code! Claims may be denied even if the problem was just because of the secondary CPT/ICD9 code! Again as I previously pointed out with my other articles on tracking your claims, with this problem, discuss solving the coding error rather than how much you want to get reimbursed. Most of the insurance companies will help you with codes (in fairness!!) and they also inform you on outdated codes, or codes that requires a 5th digit. Be nice with the claims department! (at least you try!)
(4) Incorrect use of
Seemingly insignificant issues in the workplace can, if left to fester, evolve into debilitating conflicts that affect teams, departments, even the whole organization. Is impending crisis looming in your workplace? Here are some warning signs:The same issues keep coming up. If you thought you resolved the problem but it keeps resurfacing, be careful. This just may be the tip of the iceberg.When a conflict starts to escalate, related issues keep popping up around it. Sometimes we'
(4) Incorrect use of modifiers! (be careful with bilateral procedures!, modifiers for professional and technical component, modifiers for multiple procedures, postoperative period, etc.)
(5) No precertification or preauthorization obtained (if required) It is so hard to file an appeal when the claim or service was non-precertified. Avoid it from happening!
(6) No referral on file (if required) Note: HMOs always requires a referral! (remember that!)
(7) The patient has other primary insurance or the patient’s claim is for workman’s comp or auto accident claim! It is the responsibility of your front desk staff to get all the necessary information before the patient can be seen. Remember that if this is a workman’s comp or an auto accident claim, you need a claim number and the adjustor’s name. Services are always preauthorized!
(8) Claim requires documentation & notes to support medical necessity A well documented medical records is a good practice!
(9) Claim requires referring physician’s info (with UPIN ofcourse!-this will be soon replaced by an NPI or the National Provider Identification number)
(10) Untimely filing Unfortunately
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