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Linda Collins Blogger

Common Claims Denials

Posted by Linda Collins | October 13, 2015

A clean claim is one that has no defect or omission, including incomplete documentation, that delays timely payment. Of course, that is the ideal situation. In reality, claims are delayed or even denied for simple errors.  In fact, The University of Minnesota estimate that 30% to 40% of bills contain errors. The Medical Group Management Association (MGMA) reports that top performing  medical groups average a 4% claims denial rate.

What is your practice's denial rate? If you are close to 4%, then congratulations. If your rate is higher, then time to look at your office processes for claims submission.

One of the main reasons for claims denial, according to Medicare, is invalid procedure code and/or modifier. Other top reasons for Medicare denials are invalid patient's Medicare ID (HICN) and invalid NPI number. Manual errors, input oversights and timing issues could be causing more denials than you realize.

Here are a few data points to check on all claims:

  • The patient's name spelled correctly with first and last name in correct box.
  • Accurately enter the insurance policy number or ID number.
  • The referring physician's NPI matches his name and office location in PECOS.
  • Spell the physician's name is exactly as it appears in PECOS.
  • Enter is a valid HCPCS code to describe the product. Verify the code is correct and valid code for the product being delivered.
  • Use an appropriate modifier for the HCPCS code.
  • Include charges for each HCPCS item. (The charge is the amount you bill. The payer will adjust the amount to match the contract fee schedule.)
  • Service date is prior to the date of claims submission (Yes, this is one of the top errors according to Medicare)
  • Submit the claim to the correct address or Medicare contractor. They will not forward claims for you.
  • Submit the claim in a timely manner. (Private payers have time limits on claims submission. Missing the deadline can result in a timely filing denial.)

Check your process, pay attention to the details and submit clean claim. Otherwise, you're just allowing money to slip through the cracks.

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