Top Reasons for Claim Denials in Medical Billing & How to Prevent Them

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Claim denials severely affect a healthcare provider's revenue cycle, leading to delayed reimbursements and monetary losses. Effective accounts receivable-and-denial management is crucial for cash flow and reducing rejected claims. In specialty areas like orthopedics, precision in orthopedic coding is required to avert errors leading to rejection.

Common Reasons for Medical Billing Denials

• Incorrect or Incomplete Patient Information - Errors with patient demographic information, insurance details, or policy numbers cause immediate rejection of claims.
• Lack of Medical Necessity - Payers will deny claims if the documentation does not justify medical necessity of a procedure, especially for orthopedic treatment.
• Coding Errors & Incorrect Modifiers - Potential denials may arise from wrong coding in CPT, ICD-10, or HCPCS. Medical necessity documentation with a correct coding frame of an orthopedic process is key in ensuring proper claim submission of orthopedic procedures like joint replacements or fracture treatment.
• Duplicate Claims – Submitting the same claim multiple times may simply lead to an automatic denial.
• Timely Filing Issues - A claim submission is expected to follow set deadlines defined by each insurer, and failure to recognize these timelines may cause rejection of the claim.

How AR and Denials Management Can Help

Proactive AR and denials management requires regular claims audits, documentation, and timely follow-ups for the prompt resolution of rejected claims. Delegated billing services are of utmost importance to orthopedic practices in ensuring accuracy of orthopedic coding, thus helping to reduce claim denials and enhancing revenue cycle operations.
 

Healthcare providers can improve efficiency and maximize reimbursements by capturing these common denial reasons alongside efficient billing practices.

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