Earlier we talked about 4 issues that could affect your practice’s medical billing. This time we are going to touch upon a few more reasons why your claims could be denying.
Services That Require Authorization
Certain services require pre-authorization to be completed. This is a decision made by the insurance payor that the services the patient needs is medically necessary. This could be a call into the insurance company, or a form to be completed and faxed. Once the initial authorization is received, then the service should be covered. The insurance payor will let you know the authorization information including the number of days or visits and within what period of time.
Once the initial authorization units are used, you may need to request additional units through what may be known as a “concurrent review” completed by the insurance company.
This usually must be done before the service is rendered. If the service rendered required an authorization but you did not complete one, then the insurance payor can deny the claim. When verifying benefits, you can request information on the specific penalties that can occur if authorization was not received for certain services. Sometimes claims are denied, sometimes there may be other monetary penalties depending on the insurance company and the insurance plan. Insurance companies also have different policies with regards to how much time before a service is rendered must the authorization be done (for example, 24 hours within the time the service was rendered).
Therefore, it is very important to figure out which services need an authorization and to get the authorization before these services are performed, so your claims will not be denied.
Services That Require Referrals
Likewise to authorizations, some services require referrals from a primary care physician. This means writing the patient a proper documentation for them to see a specialist or to receive certain services. Depending on the insurance payor, the plan, and services rendered, this may be required and insurance can deny claims if the referral was not received.
Duplicate Claims
Due to reasons such as human error, sometimes the same claim, for the same patient, on the same date of service could be submitted. If the insurance payor decides it to be the same exact claim, they can deny this as well. Therefore, to avoid this mistake, it is even more important to create proper coding and billing procedures at your practice and to organize the information in a system that will be followed by your staff.
Insufficient Proof of Medical Necessity
Payors may need medical proof of necessity to make decisions on claims sometimes. If they do not deem the treatment as necessary, then claims may be denied for that service. They may also request additional medical information such as medical history, notes, reports, etc., anything to support the need for the service, before making a decision on payment.
COB Is Not Up-to-date
COB, or a coordination of benefits, is something that lets insurance payors know which insurance policy the patient has is primary and which is secondary. Usually the policy holder will need to contact insurance and get this updated if they have more than 1 policy.
Some insurance companies send out a coordination of benefits request every year for the policy holder to complete regardless of whether they have more than 1 policy or not. Sometimes, insurance payors will deny claims if the coordination of benefits is not up to date by their policies. Therefore, this could be another reason why claims are denied.
Insurance payors will usually put a code on the Explanation of Benefits (EOB). They will also include a description of the code. For more information, the person in charge of following up on claims at your medical practice can call the insurance company and ask the claims department why claims are denied and what can be done to resolve these issues.
If your clinic is facing difficulties with claims management, denials management, and claims follow-up, contact us today to learn more about how Americare Network can help your practice.
