Issuu on Google+

Top 8 Denial Reasons


Top 8 Denial Reasons Classification Claim not on file (Medical Billing Star responsibility)

Description

Action that is taken by the Medical Billing Star

In most cases the claims sent out to local insurance companies by paper are the ones that need to be resubmitted as the Insurance companies do not have the initial claims that are sent. billing office ensures that all unpaid claims are called and checked with the respective insurance companies within their filing limits.

Medical Billing Star already follows up on these claims and ensures that the claims are resent within the filing limits

Insurance companies require separate documentation like, Primary insurance company’s explanation of benefits, the coordination of benefits from the patient, accident details etc .

The billing office ensures that the primary insurance companies EOB is sent out to the secondary Insurance company. All other requests for further information is forwarded to the Patients by statements

This is normally the case when patient is billed for the payments as they lack an insurance plan and these claims are kept open until we receive payments from the patients

Medical Billing Star ensures that all payment statements are sent across to the patients in a timely manner

This is normally the case when the patient has a insurance plan which has termed before his date of service and so the payment statement is sent out to the patient for payment

Medical Billing Star ensures that all payment statements are sent across to the patients with an explanation that their plan has been terminated and that they would have to get back with valid insurance information

The provider for certain procedures gets an approval or authorization number from the insurance company before they go ahead. In most cases the authorization number is not mentioned by the provider’s office in the documents sent over to the billing office. Insurance companies deny claims for these certain procedures on these grounds

Medical Billing Star gets back to the provider for information about the authorization number that they should have received. If they get the required info, the claim is resubmitted to the Insurance company

Additional Information (Provider/Patient 2 responsibility) Patient responsibility 3 (Patient responsibility)

Patient not valid 4 (Provider responsibility)

No Authorization/Referral# 5 (Provider responsibility)


Top Reasons ‌ Insurance

companies

have

an

approved

list

of

procedure/diagnosis combinations that they would pay

Invalid CPT code/ Dx code

for. Medical billing star maintains a database of the approved

combinations

by

different

insurance

companies. Our experienced coders ensure that the

(Medicalbillingstar responsibility)

highest paying approved combination of procedure and

Mutually Inclusive

Modifiers are required for certain claims to be able to tell

diagnosis codes are used to ensure maximum payment

the insurance company that the procedure billed for is a

(Medicalbillingstar responsibility)

revaluation based on a previously billed procedure code. These

are

reworked

by

the

billing

offices

and

resubmitted within the filing limits

these claims and ensures that CPT/ICD codes are corrected as per the respective insurance companies and resubmitted within the filing limits

Medicalbillingstar already follows up on these claims and ensures that the necessary modifiers are included and the claim is resubmitted

within

the

filing

limits

Medicalbillingstar ensures that all payment

Services not covered This is when the patients insurance does not cover the

(Patient/Insurance company’s responsibility)

Medical billing star already follows up on the

procedure performed by the doctor and in most cases the payment statement is sent out to the Patient

statements are sent across to the patients with an explanation that the services that were charged to the insurance company are not covered for their plan


Over a 5 month period with our existing clients. Sl No

Categories

# of issues

Charged amount

Amount Received

1

Claim not on file

205

14284.8

5713.9

2

Invalid CPT code/ Dx code

17

4196.8

1678.7

3

Mutually Inclusive

16

1229.3

491.7

4

Additional Information

200

24614.3

9845.7

5

Patient responsibility

96

10438.7

4175.5

6

Services not covered

36

9610.9

3844.3

7

Patient not valid

61

3054.9

1222.0

8

No Authorization/Referral#

49

6407.3

2562.9

680

73837.0

29534.8

*approximate values, based on 40% of the charged values


Denial Reasons - # of issues 49, 7% 61, 9%

205, 31%

36, 5%

96, 14% 17, 3% 16, 2% 200, 29% Claim not on file

Invalid CPT code/ Dx code

Mutually Inclusive

Additional Information

Patient responsibility

Services not covered

Patient not valid

No Authorization/Referral#


Denial Reasons – Amount Received 2562.9, 9% 5713.9, 19%

1222.0, 4%

3844.3, 13% 1678.7, 6%

491.7, 2%

4175.5, 14%

9845.7, 33%

Claim not on file

Invalid CPT code/ Dx code

Mutually Inclusive

Additional Information

Patient responsibility

Services not covered

Patient not valid

No Authorization/Referral#


Medicalbillingstar also maintains an internal database of rejected and underpaid claims of various carriers to serve as an expeditious source of reference for similar cases in the future. This drastically cuts down our denial management time-frame and puts the money where the mouth is, i.e. the physician’s pockets


medical billing services