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A new report shows that medical claim denials have increased by 23% over the last four years.
Since the onset of the COVID pandemic last year, claim denials have climbed by 11% nationally.
What's going on?
Medical Claim Denials Up 23% Since 2016,
A Pre-Pandemic Problem
Although the pandemic appears to be aggravating the problem, the rise in medical claim denials had already begun before the COVID outbreak, according to 2019 data.
In addition, a report issued by the American Hospital Association (AHA) in December of last year confirms that 89% of hospital administrators have witnessed an increase in denied claims over the last three years. About half of the AHA respondents described the increase as “significant.”
The AHA believes that claim denials are not only impacting revenue performance for healthcare providers, but also the quality and accessibility of patient care. (See box, "Denials Fueling Burnout.")
eighty-six percent of the denied claims between July 2019 and June 2020 were potentially avoidable, the analysis suggests. (Only 14% of them were deemed unavoidable.)
A large portion of the claims were denied because of missing or incorrect data, missing or invalid explanation of benefits, and service not covered.
In other words, most of the revenue loss attributed to these denials is preventable.
Top Reasons Claims Are Denied
Here are the most common reasons insurance carriers deny claims:
Denials Fueling Burnout
The AHA believes that private health insurance carriers are abusing practices like prior authorization and claim denials, resulting in more clinician burnout and barriers to patient care for patients.
In 2019 the AHA surveyed more than 200 hospitals and healthcare systems about ways in which pre-authorization and denial practices affect their operations. The association also interviewed several hundred hospital and health system executives.
While the analysis was conducted pre-pandemic, the AHA said COVID-related staffing shortages have made addressing prior authorization and denial issues "increasingly urgent."
Source: Becker's Hospital Review
Failure to Obtain Pre-Certification
Failure to obtain authorization prior to treatment was one of the top reasons for claim denial, according to the AHA survey. It is essential that staff members responsible for submitting insurance claims be highly knowledgeable of which insurance carriers require pre-authorization for which treatments.
An American Medical Association (AMA) survey also found that 86% of physicians’ offices rate the burden of pre-certification as “high” or “extremely high.” On average, these offices devote two business days per week just to addressing prior authorizations.
Another common mistake that leads to claim denials is providing inadequate information to the insurance company. Omitting even the smallest detail (such as treatment date, date of onset or demographic information) can result in an unpayable claim.
Using incorrect codes or referring to an obsolete codebook occurs far too often, resulting in claim denials and revenue loss.
In addition, proper documentation must be present when coding and submitting claims. Otherwise, insurance carriers will assume that the services were not performed.
Duplicate claims can occur when a staff member neglects to remove a claim from the patient’s account after it has been resubmitted. Most claims processing systems can detect and flag duplicates. If the original claim appears as a duplicate, it could result in a claim denial.
Which means simply preventing duplicate claims is not enough. Original claims must be properly coded with the required modifiers and documentation in order to identify the bill as an original and not a duplicate.
Even legitimate and properly coded claims can being denied if not submitted in a timely manner. For instance, the deadline window for submitting Medicare claims was reduced by the Affordable Care Act to 12 months after the date of service. (It had previously been 15-27 months.)
What’s more, filing deadlines vary between insurance carriers. Failure to meet these defined deadlines can result in some serious revenue loss.
Failure to Verify Coverage
Healthcare insurance is changing all the time. Which means eligibility must be verified every time services are provided. Tedious? Yes. But it could save your practice a substantial amount of money down the line.
The Answer? Partner with RFS!
We make sure medical claims don't fall through the cracks and end up being denied for avoidable issues. And we'll continue to follow up on all denied claims until they're resolved.
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Colorado Springs, CO 80909
P.O. Box 140
Colorado Springs, CO 80901