What Are the Types of Denials in Medical Billing?
This post was last updated on May 5th, 2022
Medical billing is the process of realizing the benefits a customer deserves from an insurance company. When a claim is filed to receive insurance benefits, it is expected to follow a set of guidelines and processes. It must follow the required codes and procedures so that the process happens without any hassles. This claim is expected to contain information about the subscriber like the demographics, what procedures have been performed, when and why they were performed, and how much they cost. If the details are improper or untrustworthy, the subscribers may not receive the benefits they deserve. Hence, it is critical to understand how errors might happen in medical billing.
Errors could lead to two kinds of reactions from the insurance company: Rejections and Denials. Rejection is when the insurance provider does not even understand what is filed. Rejection could be due to incorrect codes or details that can’t be processed. As expected, the insurance provider says an outright no. On the other hand, denials happen for various reasons as discussed below.
Understanding Types of Denials in Medical Billing Services
Denials happen for reasons like missing information, or questions regarding whether the services that are claimed are actually covered under the insurance policy, or the authenticity of the data that is provided to the provider, or such factors. We can categorize them into two broad types: Hard and Soft.
Hard denials are those that we cannot reverse. They occur when the claim is filed for matters beyond what the policy promises to cover- at least that’s what the insurance provider feels about it. As such, they are irreversible and can’t be appealed. On the other hand, soft denials are those which occur whenever sufficient information is not provided in the claim, or when the claim is filed incorrectly. Subscribers can receive the estimated benefits if this information is corrected and appealed.
Most of these denials happen because of slip ups in medical billing services. Some such slip ups happen:
When the required information is not provided
The claim contains a missing detail, like the subscriber’s social security number is not filled, an important field is left blank, there are incorrect plan codes mentioned, and so on. These errors lead to around 42% of total write-offs.
The claim that is filed is duplicate
This occurs when the claim is filed more than once for the same event. The claim contains details like the same beneficiary, date, provider, and for the exact encounter, all that is already mentioned elsewhere. Here you can find the best personal injury lawyer.
Pre-adjudicated services
The claim is filed such that it was already included as part of other larger claims, and the insurance company processed and decided on the matter already.
Services not covered under the insurance policy
Sometimes, claims are filed on services that are not covered under the insurance plan. Such benefits are denied to the extent they are not included.
Insurance claim passed expiration period
If the claim filed is after a certain amount of time as prescribed by the insurance provider, the benefit is again denied.
Hence, to ensure no stone is left unturned, claims are to be made with proper caution. It might also be a better idea to take the advice of experts on medical billing services to minimize damage.
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