Missing patient information denials and resolution
Patient information is one of the important parts of creating a clean claim. About 20-30 percent of rejections or denials occur due to lack of patient information. Some of the rejections and denials are patient name, DOB, Gender, member ID# is incorrect and member policy termed.
The correct resolution for all patient demographic information denials or rejections is to check eligibility. Various insurance web tools and private vendors have the option to verify member eligibility. It is good to check patient eligibility verification before filing the claim to avoid rejections or denials. If the patient information is incorrect still, then calling and obtaining that information is advisable before billing the patient.
Also other additional information such as pre-existing conditions, cause of injury or illness and dependent details are also to be verified, especially for a new patient.
Charges related denials and resolution
Basically charge related denials are among 15-20% of single practice denials. Most Charges pass through the edits in the clearing house when submitted electronically. Some of the edits are inbuilt as protocol loops. So whenever a claim gets rejected, the clearing house informs with a rejection note. But, the claims which bypass those edits will be denied by the payer stating it is non payable due to billed amounts, units, and procedure or diagnosis codes.
Federal payers like Medicare, Tricare and the Department of VA deny any billed charges or units which are outside their fee schedule range. In cases like these it is important to visit that particular payer’s web portal and download their fee schedule or upload that fee schedule in the PMS if that option is available.
Coding denial management can be resolved using a coding tool, by cross verifying with the progress notes/charts. Implementation of ICD 10 new codes in extra defining the specific procedures unlike ICD 9 which had more unspecified codes. Tools like Encoder pro or super coder can cross verify in coding related denials and rejections.
Frequently Asked Questions
Missing or incorrect patient information, incomplete documentation, and inaccurate coding are the leading causes of charges-related denials.
Missing information delays claim submissions and increases the likelihood of denials, leading to delayed payments and higher administrative costs.
Ensure thorough data collection during patient registration, verify insurance details, and conduct regular audits to avoid missing information.
Quickly addressing and correcting denied claims ensures timely reimbursement, reducing revenue delays and improving overall cash flow.
