Advanced Revenue Cycle Analytics: An Overview

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Every practice deals with the headache of denied claims. Insurance companies are strict, and their rules are constantly changing. It takes a lot of time and attention to detail to keep a low denial rate. Reducing your denial rate is a critical way practices can improve their revenue cycle outcomes. A low denial rate and seamless denial management process is key to getting paid what you are owed for your services.

In order to lower your denial rate, it is important to know the main causes of denied claims. Read through this list, and take note of areas where your practice is prone to make errors.

1. Duplicate Claims

There are several reasons that a claim will get denied as a duplicate claim.

  1. The same claim was submitted to the insurance company twice, but the service was performed only once.
  2. The same service was performed by a different provider on the same day, and it was processed prior to your claim.
  3. The same service was performed twice by a provider without indicating it with a modifier.
  4. The same service was performed bilaterally without including the appropriate modifier.
  5. The claim is corrected, but did not state that it was a corrected claim.

2. Patient Coverage Terminated

This type of denial occurs if the provider performs services after the patient’s coverage has ended. To deal with this type of denial, you first want to check with the insurance company on this patient’s policy end date. If you find that their policy was still active at the time of service, then submit the claim for reprocessing.

The next step is to contact the patient to find out if they have any other active insurance coverage. If they do not, then you will bill the patient. This type of claim denial is why it is so important to verify insurance before you perform any service. It will save you time and money to know ahead of time how the patient is planning to pay.

3. Patient Has Not Met Deductible

In this scenario, the patient has not yet met the deductible for the calendar year. This is commonly the case as higher deductible health plans are on the rise in the U.S. Many patients do not have the means to pay for their care. Again, this is why it is important to verify with the patient how they plan on paying for care before they receive any treatment.

4. Bundled Services

Providers cannot bill separately for bundled services. For example, laboratory profiles with multiple tests don’t qualify for separate reimbursements, or an all-encompassing rate covers the minor procedure and the pre- and post- procedure visits. The provider receives one combined payment.

5. Benefits Exceeded

This type of denial will occur when the benefits offered for this type of service have been exceeded by the patient. There may be a dollar amount that an insurance company will pay for a certain service, or it may be the number of times a patient can have a certain type of visit per year.

6. Incorrect or Missing Modifiers

Claims are often denied in cases where there are missing modifiers, or where the modifiers included are invalid. There are some modifier and CPT code combinations that are invalid. Other times, there are modifiers that cannot exist together on the same line item or claim form.

Our software can prevent incorrect or missing modifiers. AccelaCAPTURE is an automated charge entry software that allows physicians to enter charges as quickly as they did on paper. These charges are run through our rules engine, AccelaSMART, which will catch any incorrect or missing modifiers.

7. Inconsistent Place of Service

Claims will be denied if the place of service does not match the service billed. For example, if an inpatient procedure was billed in an outpatient setting, this will result in a denied claim.

8. Service Is Not Covered

When an insurance company does not cover this particular service under the plan, the full financial responsibility falls to the patient. This is another example of the importance of insurance verification before the time of service. By the time of a patient appointment, there should be no doubt who will cover the bill.

9. Missing Information on a Claim

Claims will be denied if the claim is deficient in certain information. It may be missing prior authorization or the effective period of time within which the pre-approved service must be provided for reimbursement to occur.

10. Procedure Code Billed With Inappropriate Diagnosis Code

This claim denial occurs when the CPT code and ICD-10 codes are inconsistent with one another. This is another problem that our AccelaSMART software can catch, allowing your coding staff to quickly resolve the error before the claim is ever sent out.

11. Bill Liability Carrier

When it comes to auto or work-related accidents, some insurance carriers refuse to pay until the auto insurance or worker’s compensation carrier has been billed.

For accident-related services, the following third party liability insurance should always be filed as primary:

  1. Motor Vehicle or Auto Insurance including no fault, policy or Med Pay
  2. Worker’s Compensation Insurance
  3. Home Owner’s Insurance
  4. Malpractice Insurance
  5. Business Liability Insurance

12. Filing Deadline Passed

Claims that are not submitted within the deadline will be denied. This is why efficient and timely coding and claim submission is so important. The limit to file a claim can be as short as 90 days from the date of service.

13. Patient Information Error

Human error can result in incorrect patient information. This denial is a result of errors or typos made while collecting pertinent information from the patient or during the data entry process for a claim.

Struggling with denials? Let White Plume show you how we can help your practice:

  • Reduce Denied Claims
  • Save Your Team More Time on Charge Entry
  • Automatically Capture More Missed Charges
  • Improve Claim Accuracy With Coding Validation

Download our free Denial Management Guide to see specific denial codes and reasons. You can also use our Denial Calculator to see how much denied claims are costing your practice.