Claim rejection is one of the most frustrating things for medical and healthcare providers. The rejection of a claim can happen for many reasons, and while one here and there might not seem like a big deal, the impact of rejected claims can be significant for a practice.
Let’s delve into the most common reasons a claim is rejected and a few practical tips on how to avoid them. First, though, let’s look at what a claim rejection entails.
What are claims rejections?
It’s important not to confuse a claim rejection with a claim denial. Claims rejections occur either at the clearinghouse or the payor. It usually happens because of a problem or mistake with the information included on the claim form. The claim is then returned to the practice for correction.
A claim denial, on the other hand, is a claim that is received, processed, and then denied. This usually pertains to issues with eligibility and coverage, authorization issues, misinformation, etc.
The Most common reasons for claim rejection
Incorrect or missing information on the claim form
Probably the most common reason that a claim is rejected is simple mistakes on the claim form. This could be in the form of missing or incorrect information. Insurance providers require specific details to assess and process claims accurately. Missing information, such as a DX code or a patient’s date of birth, could stop the payor from entering the claim into their system, leading to a rejection. The same goes for incorrect National Provider Identifier numbers or insurance details.
Every form should be carefully checked before it is sent to avoid missing or incorrect information. All fields must be filled out accurately, and you should double-check that all information is included. Always keep your patients’ information and records up to date, communicate clearly with them regarding their information, and ask whether their information is correct before sending a claim.
Errors in billing and coding
Claim rejection codes and billing errors are seen far too frequently. Health insurance providers rely on specific ABA therapy code sets, such as the ICD-10 codes that identify the underlying medical diagnosis and the Current Procedural Terminology (CPT) codes, which describe the specific ABA services that were provided. If there is an error or the code is incomplete, insurers won’t be able to process the claim, and it will be rejected.
It’s essential to stay up-to-date with the latest coding guidelines and ensure the correct codes are used on claims forms. Staff should be regularly trained and updated on codes and coding practices to minimize errors and subsequent rejections.
Prior authorization and referral issues
Many medical procedures and treatments require pre-authorization and approval by an individual’s medical insurance provider. Failure to obtain the necessary approval and proof of this in the claims form will result in rejection.
To avoid this, ensure that you and your staff have in-depth knowledge of your clients’ insurance providers’ pre-authorization requirements. Understand which treatments need pre-approval and make sure that your practice obtains the necessary documentation to show approval before rendering services. Keep this documentation for future reference.
Duplicate billing
Some claim management systems don’t flag duplicate billing claims. This means the clearinghouse or payor receives billing for the same services twice.
To avoid this, your practice should have an advanced claim management process that includes a system capable of reviewing claims and detecting duplicate billings.
Timeliness of filing
Most insurance providers will have a mandated time frame for the submission of a claim, which will occur after the treatment date. If you file a claim after this timeframe has lapsed, the claim will likely be rejected.
Always ensure that your team follows timely filing procedures and implements processes that ensure no claims are left too late.
Outsourcing your medical billing could be the answer
Missing Piece is a reliable ABA therapy billing service provider. We will lower your claim rejections by ensuring they are processed quickly and easily. Our advanced technology and billing process allows us to do the heavy lifting on the administrative side while you concentrate on giving your patients the quality care that you are known for.
With over 10 years of experience in the industry, we are the right billing provider with a flexible service that you can scale up and down as you need. Lower your medical claim rejections with Missing Piece. Contact us to find out how we can help your practice.