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Insurance claim denials can be costly for any family medicine practice. Denials may lead to one of two different scenarios:
A. If the denial is not applicable, your practice will experience a loss of income for a service already performed; or,
B. You will incur increased expense in appealing the denial — a situation no practice wants to be faced with, particularly as reduced payment from many payers affects practice income.
1. Verify Insurance Plan Coverage every time: While this may seem obvious, in fact the number of claims denied or returned because the wrong insurance carrier is billed is staggering. It is the number one reason claims are not paid upon first submission.
2. Billing for services found to be “medically not necessary”: This is a second reason claims are commonly denied or not paid. All too often, practices write this money off and do not bill the patient for these services.
You can be proactive in reducing these denials by knowing which of the services you provide are tied to specific diagnoses, time periods (e.g., annually, biannually, every five years) or other payment conditions. Next, implement a policy to address how to bill for these services if one of the conditions is not met.
3. Updating Codes (ICD-9, CPT, HCPCS): Every year the code sets used to report and develop insurance claims are updated. Using invalid codes is a frequent source of claim denial.
4. Obtaining a copy of the member’s current insurance card at all visits, as policies can often change. This will ensure that the claims are submitted with the most current policy information.
5. If a corrected claim is needed, it must be marked as “corrected claim”, and indicate what is being corrected. If the corrected claim is not marked as such, it may be denied as duplicate or the issue may not be resolved appropriately
6. Be sure to include all current and complete provider information on the claims, including the current tax identification number and NPI numbers in the correct fields
A. If the denial is not applicable, your practice will experience a loss of income for a service already performed; or,
B. You will incur increased expense in appealing the denial — a situation no practice wants to be faced with, particularly as reduced payment from many payers affects practice income.
How to avoid insurance denial
Here are the important points1. Verify Insurance Plan Coverage every time: While this may seem obvious, in fact the number of claims denied or returned because the wrong insurance carrier is billed is staggering. It is the number one reason claims are not paid upon first submission.
2. Billing for services found to be “medically not necessary”: This is a second reason claims are commonly denied or not paid. All too often, practices write this money off and do not bill the patient for these services.
You can be proactive in reducing these denials by knowing which of the services you provide are tied to specific diagnoses, time periods (e.g., annually, biannually, every five years) or other payment conditions. Next, implement a policy to address how to bill for these services if one of the conditions is not met.
3. Updating Codes (ICD-9, CPT, HCPCS): Every year the code sets used to report and develop insurance claims are updated. Using invalid codes is a frequent source of claim denial.
4. Obtaining a copy of the member’s current insurance card at all visits, as policies can often change. This will ensure that the claims are submitted with the most current policy information.
5. If a corrected claim is needed, it must be marked as “corrected claim”, and indicate what is being corrected. If the corrected claim is not marked as such, it may be denied as duplicate or the issue may not be resolved appropriately
6. Be sure to include all current and complete provider information on the claims, including the current tax identification number and NPI numbers in the correct fields
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