Medical Billers and coders work tirelessly on claims to ensure that they are paid on time. However, these claims can still be denied for a number of reasons. For instance, some denials happen because vital information was not included on the forms. In other cases, the healthcare insurance company may have inefficient processes. Therefore, we have compiled some common reasons why medical billing claims in the American healthcare industry get denied. 

1.    Late Claims    

Most insurance companies allow 60 to 90 days to file a claim, so if the claim is filed too late after the service is provided it will be denied.

2.    Wrong or Missing Billing Codes 

Incomplete, invalid, or missing International Classification of Diseases, Revision 10 (ICD-10) and Current Procedural Terminology (CPT) codes will result in payment delays or the claim will be rejected. 

3.    Lost or Expired Claims

Claims have to be entered into the insurance company’s system to be processed. If the claim is lost by the healthcare insurance company and is not found before the expiry date it will not be paid.

4.    Unauthorized claims

Preauthorization is required for some medical services. If the services are provided without proper authorization the claims will be rejected automatically.

5.    Two services are provided in one day

Insurance companies may have a strict policy of paying for only one service per day. Whether the patient is authorized for 10 sessions or more, if they receive two sessions a day, the second claim will be denied. Therefore, it is necessary for clinicians who provide group therapy, medication or psychological testing or treatments to remember this rule.

6.    A proper referral from a physician was not obtained

Some insurance policies require prior authorization and referral from the primary care provider (PCP) or a specialist. If services are provided without a referral the claim will be rejected.

7.    All authorized sessions have been used

Sometimes authorization is granted for a certain number of appointments or services. Additional sessions or services will not be paid without a new authorization.

8.    The prior authorization expired

Prior authorizations may have an expiration date and sometimes they expire within 30 days. If the services are not provided within the approved timeframe claims will be denied. 

9.    A change in the patient’s health insurance 

When patients change their insurance policy they must do the following to avoid denied claims:

a)     Get new preauthorization

b)     Make sure that their provider accepts their new insurance and that the provider is in the network.

10. Health insurance is canceled

Providers should always check that patients have active insurance coverage because patients may not even be aware that they have lost their health insurance. Claims submitted under a canceled heath insurance policy will be denied.

About The Author

Aiden Spencer is a Healthcare IT Researcher who focuses on various engaging and informative topics related to the health IT industry. Connect with him on Twitter.

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