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Most Common and Avoidable Claim Denials

Claim denials are a common occurrence in the healthcare industry. In fact, according to Change Healthcare, 61% of initial medical billing denials are due to demographic and technical errors. This means that many claim denials are avoidable.

Here are the most common and avoidable claim denials:

  • Missing or incorrect patient information. This includes the patient's name, date of birth, insurance information, and Social Security number.

  • Incorrect or incomplete coding. This can happen when the wrong CPT or ICD-10 code is used, or when the codes are not properly supported by the medical documentation.

  • Unbundling. This occurs when multiple codes are submitted for a single service.

  • Duplicate claims. This happens when the same claim is submitted multiple times.

  • Pre-authorization requirements not met. Some services require pre-authorization from the insurance company before they will be covered.

  • Claims not submitted within the timely filing period. Each insurance company has its own timely filing period, which is the amount of time that a claim must be submitted after the date of service in order to be considered for payment.

By taking steps to avoid these common mistakes, healthcare providers can help to reduce the number of claim denials they receive.

Here are some tips for avoiding claim denials:

  • Make sure that all patient information is accurate and complete.

  • Use the correct CPT and ICD-10 codes, and be sure to support them with the appropriate medical documentation.

  • Avoid unbundling services.

  • Check for duplicate claims before submitting them.

  • Ensure that all pre-authorization requirements are met.

  • Submit claims within the timely filing period.

By following these tips, healthcare providers can help to ensure that their claims are processed smoothly and efficiently, and that they receive the payments they are due.

In addition to the tips above, there are a few other things that healthcare providers can do to help avoid claim denials. These include:

  • Having a dedicated team of professionals who are responsible for claims processing.

  • Investing in a medical billing software system that can help to identify and prevent errors.

  • Working closely with insurance companies to understand their specific requirements.

  • Staying up-to-date on changes to coding and reimbursement rules.

By taking these steps, healthcare providers can help to reduce the number of claim denials they receive and improve their cash flow.

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