October 7, 2019

Medical claim denials are a problem that all healthcare providers, regardless of size, specialty, and past experience, face on a daily basis. Billing managers and Accounts Receivable staff spend countless hours submitting, correcting, and re-submitting patient claims to insurance providers for payment. This inefficiency not only costs healthcare providers time and money, but also drives up the administrative expenses of insurers and ultimately leads to greater costs for patients throughout the entire healthcare industry. 

What causes medical claim denials?

So what exactly is causing all of these denials, re-submissions, and inefficiencies throughout the system. According to Debra Beaulieu-Volk in Medical Economics magazine, a dozen of the most common causes for medical claim denials are as follows:

  1. Data entry and/or typographic errors on patient data
  2. Duplicate claims submitted for the same service
  3. Missing or incorrect procedure code modifiers
  4. Inaccurate site of service designation
  5. Outdated or deleted diagnosis codes
  6. Patient plan’s deductible has not been met
  7. Mutually exclusive or mismatched diagnosis codes
  8. Patient has exceeded his/her plan’s benefit amount
  9. Lack of prior authorization approval by patient’s plan
  10. Service rendered is not covered under patient’s plan
  11. Service rendered is deemed not medically necessary 
  12. Providing physician is outside of patient plan’s network                                                                                                                                                  

How can medical claim denials be reduced?

Don’t make these mistakes in your practice! In order to eliminate the efficiencies in the billing and collections process, an organized, coordinated system of procedures must be established and followed on a consistent basis. Fortunately, these procedures and best practices do exist, and can be adopted and successfully implemented by any organization with the right help and guidance.

In fact, GBS’ RCM services have been shown in the past to reduce provider denial rates to less than 1%, adding dollars directly to the bottom line by increasing revenues and reducing costs. Contact GBS today to learn more about the billings and collections solutions that can help turn your practice around!                                                                                                                                                                                                                           

Beaulieu-Volk, Debra. “Improve the Claims Management Process: Preventing Payer Denials.” Ensuring Medical Billing Success, 30 May


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