Medical insurance claim submission is a critical step in the medical billing process. It determines the reimbursement the healthcare provider 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 business.
However, even the most diligent practices can fall prey to common mistakes that lead to denied or delayed claims. According to the American Medical Association (AMA), health plans make errors in nearly 1 out of 5 claims.
Therefore, understanding and addressing these errors can significantly improve your claim acceptance rates 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 rejecting claims.
A Ponemon Misidentification Report states that the average hospital loses $17.4 million annually in claim denials based on misidentification. The report also adds that “hospitals have 30% of all claims denied, and an average of 35% of these denied claims are attributed to inaccurate patient identification or inaccurate/incomplete patient information”.
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 These mistakes can include using outdated codes, misinterpreting coding guidelines, or selecting the wrong codes for the procedures and diagnoses.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.
The American Academy of Professional Coders (AAPC) states that health record documentation alone supports coding, which supports billing. Providing only a copy of the encounter form to support a service, for example, will result in denial of payment. Charge slips, superbills, and encounter forms aren’t part of the health record and are not legal evidence that a service occurred.
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!
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