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