11 Common medical billing mistakes that cause denials

Claims denials are a significant cause of stress in the medical world, and with hospitals submitting almost 100% of claims more than once, it’s also a prevalent problem!

If you find yourself struggling with an overwhelming amount of claims denials, here are a few things to double-check before submitting!

1. Typos or errors in the patient data

Error-free claims are key to avoiding denials! Even small errors like misspellings can cause your claim to be rejected. Double-check your patient’s data and pull up your dictionary app before submitting a claim!

2. Multiple claims submitted for the same service

Peanut butter and jelly, macaroni and cheese and salt and pepper are all better in pairs. Medical claims? Not so much! It’s easy to get codes and submissions mixed up, but it’s important to carefully inspect your claims for duplications. Otherwise, they may get denied!

3. Missing or incorrect code modifiers

Much like your math homework of days past, there is a right (and very wrong) answer for each code included on your claim. Using the wrong code or leaving the space blank can set you up for denial—and your staff for rework!

4. Inaccurate site of service designation

Turn on your GPS and drop a pin, because you’ll need to remember the exact location of each service! Mixing up service sites can cause confusion and create dreaded claims rework.

5. Outdated or deleted diagnosis codes

Just when you memorize the old codes, they change them again! Make sure you’re using the most recent codes on all your claims. Keeping your staff up to date with the latest education and certifications goes a long way toward avoiding denials.

6. Mutually exclusive or mismatched diagnosis codes

A black cat can’t be orange the same way a red ball can’t be blue. Make sure the codes you’re using for your claims don’t cancel each other out or mismatch. This is a common reason that claims are denied. 

7. Patient has exceeded their benefit amount

This is especially important in the last few months of the year! Insurance providers won’t accept a claim if the patient has already reached the benefit maximum. 

8. Patient doesn't have prior authorization from insurance

Some insurance providers require authorization before patients can receive specific services or care. If the procedure is billed before this approval has been granted, it may be denied completely or be in limbo while the insurance investigates. 

9. The patient's plan doesn't cover the services they received

There are specific things that are covered and not covered based on the insurance held by the patient. Unfortunately for you, it's different from insurance to insurance and from patient to patient. So, if you’re not sure: ASK! Due diligence on the front end will help you avoid denials later on.

10. Services are deemed unnecessary

Sometimes, patients elect to have services or procedures performed even if they aren’t medically necessary. In many cases, insurance companies will not cover these services and patients must pay out of pocket. 

11. You're out of network from the patient's plan

It’s important to stay up to date with changes in your patient’s coverage. Some insurance plans won’t cover services unless your practice is in network. And, in some cases, insurances may drop certain providers from the network who were previously covered.

The best way to stay error-free

If your staff is juggling medical billing with their other duties, they don't have the time to give your revenue cycle the attention needed to avoid denials. Outsourcing your medical billing to a team of highly-trained industry experts is the way to go if you want to minimize denials and rework while maximizing your cash flow! 

About GBS RevCycle

It's your revenue. KEEP IT.

GBS RevCycle helps your practice keep the revenue you’ve earned. More than a billing service, GBS RevCycle is a comprehensive Revenue Cycle Management solution that manages the entire revenue process. Maximize your collections, with more efficient cash management, higher earnings, maximum business valuation and quality time with patients.