Medical insurance claim submission is a critical step in the billing process that determines the level of reimbursement providers will receive from the insurance company. Submitting clean medical claims will help you reduce denials, accelerate the payment process, and ensure maximum return for your practice.
However, even the most diligent practices can make mistakes that lead to denied or delayed claims. Common issues include incomplete documentation, coding errors, or missing patient information.
These errors can have a trickle-down effect on patients, potentially leading to incorrect bills, unexpected out-of-pocket costs, and confusion about what they owe. When claims are delayed or denied due to documentation or coding mistakes, patients may face frustration and uncertainty, which can impact their overall experience and trust in your practice.
Therefore, preventing and addressing errors can significantly improve your claim acceptance rates, positively impact patients, and streamline your revenue cycle.
Here are three common errors made during medical claim submission:
1. Inaccurate patient information
One of the most frequent causes of claim denials is inaccurate patient information. This includes errors in patient names, dates of birth, insurance policy numbers, and other personal details. Even minor discrepancies can result in the payer’s rejection of a claim.
Just how bad is the problem? One survey of health technology managers found that 35% of all denied claims resulted from inaccurate patient identification or information, costing the US healthcare system over $6.7 billion dollars annually.
This mistake often occurs due to data entry errors, miscommunication, or incomplete information provided by patients at the time of service. Ensuring the accuracy of patient demographics is critical, as incorrect information can disrupt the entire billing process and delay reimbursement.
2. Incorrect coding
Medical coding errors are another significant reason for claim denials. These mistakes can include using outdated codes, misinterpreting coding guidelines, or selecting the wrong codes for the procedures and diagnoses.
Additionally, issues such as under-coding (not coding for all the services provided) or over-coding (coding for services not performed or coding at a higher level than what was provided) can lead to compliance problems and denied claims.
According to the Healthcare Financial Management Association (HFMA), exceptional attention to documentation and medical coding can increase the likelihood of an approved claim.
Accurate and up-to-date coding is essential for the claim to reflect the services rendered and ensure proper reimbursement accurately. Read more about this in our blog The impact of coding errors on medical billing: How to avoid common pitfalls.
3. Missing claim documentation
Claims can also be denied due to missing or incomplete documentation. Payers require supporting documentation to validate the necessity and appropriateness of the billed services.
This documentation can include referral forms, pre-authorization numbers, and detailed clinical notes. Without the necessary documentation, payers may question the claim’s legitimacy, leading to denials or requests for additional information. This mistake often occurs due to inadequate communication between clinical and administrative staff, or a lack of standardized processes for collecting and submitting required documentation.
Coding must be supported by clear, complete, and specific provider documentation, however, documentation alone is not enough unless it meets all required standards, including clinically valid, explicit provider documentation, and documentaion that meets payer and coding guidelines. This means that even if something is documented, it may not be codeable – and billable – unless it aligns with CPT rules, CMS policies, or payer-specific rules.
Read more about how you can improve your claim submission process in our blog 5 techniques to improve your claim submission.
At Health Prime, we can help!
At Health Prime, we understand the importance of submitting your claims properly to reduce your denial rate. This will allow you to optimize your practice, increase revenue, and ensure that you get paid for your work.
To learn more about properly submitting your claims and avoiding denials, contact us at [email protected]. Our team will set up a meeting to discuss how we can maximize your revenue by cutting costs, saving time, and collecting more!
