If you want to attain more financial success, you must overcome these common reasons for claim denials.

Denials generally fall under two categories: technicalities and medical. Denials resulting from technicalities are incurred due to missing codes or authorizations and claim to file mistakes. On the contrary, denials are considered medical when the treatment is not considered a medical necessity, or it is recognized as experimental or investigational.

Denied or rejected claims are one of the leading concerns of both the physicians and medical billing companies. Keeping that in mind, these are ten of the most common reasons underlying claim denials that you are suggested to eliminate to ensure a smoother revenue cycle and reap greater financial success:

1. The claim is submitted late, is lost, or has expired – the top-most reason for denials is a late filing of the claims. Typically, a claim period can range between 3 months to one year, depending upon the insurance provider. Patients must keep a keen eye on the timely filing of the claim. Similarly, claims that fail to register on the insurance company; system (such as lost of misplaced claims) will also be rejected.
2. The patient is not eligible for services because his health plan coverage has ended, and the patient has not furnished any proof of new insurance coverage – when patients change their insurance policy, they need to obtain a new preauthorization and must verify that their healthcare provider accepts the new insurance. Otherwise, a claim submitted with a canceled or expired insurance policy is destined for rejection.
3. The provider is not credentialed correctly – in this case, the insurance provider will face difficulties getting paid for the claims submitted. Just because they are credentialed with one provider, however, doesn’t mean they are credentialed with others too.
4. Some of the services claimed are bundled. – this occurs when two or more services are coupled together, and the provider receives one combined payment for both. For instance, when a patient gets multiple lab tests done, each test doesn’t qualify for separate reimbursement. Instead, an all-encompassing rate covers the minor procedures and the pre- and post-procedure visits. Hence, the provider is reimbursed for one combined service.
5. The benefit has been exceeded – this occurs when the patient has already received his due benefit. For instance, a patient has availed the maximum number of physical therapy visits allowed and covered under his health plan within a calendar year. Hence, he cannot claim any more benefits for the same session.
6. The claim form has a missing modifier(s) – for instance, the claim form might be missing a modifier or modifiers. Or it might be the case that the modifier(s) included is invalid for the procedure code, such as in the case of bilateral codes billed on both sides.
7. An inconsistent ‘place of service’ is marked on the claim form – for instance, an inpatient procedure might be billed n an outpatient setting, in such a case, the claim will get rejected.
8. A particular service is not covered under the plan’s benefit – it might also happen that a patient claims for a service that is entirely not covered under his insurance plan, or there appears to be a lack of medical necessity. Also, such claim denials occur when there is a mismatch between the actual diagnosis and the service performed.
9. The claim is deficient in the required information – this might occur when the claim form is inadequately filled with the needed information. For instance, it might be missing prior authorization or the effective period within which the pre-approved service must be delivered for reimbursement to occur. Hence, such cases for claims are rejected.
10. There is a coding error – if there is a coding error or any other data error with mismatch totals or mutually exclusive codes, such claims are settled for rejection.

For More Information > What do I need to do for ICD-10?

The above list is, by no means, inclusive or exhaustive. It only mentions some of the most common reasons for claim rejections. Beware of a lot more that can cause financial distress to your practice.