How To Avoid The Claim Denials To Make Your Practice Profitable?

Avoid Claim Denials

Avoid Claim Denials

According to the recent study of MGMA (Medical Group Management Association), it has been revealed that better-performing medical business average just 4.05% of the claim denial rate. If your practice is suffering from more than four percent of a claim denial rate then you need to thoroughly examine your revenue cycle management. Claim denials can occur due to a number of reasons i.e. Manual errors, input oversights, and timing issues, etc. In this article, I have provided a quick guide that can help practitioners to avoid such mistakes that result in claim denials.

1. Double-Check Incorrect or Missing Information:

Make sure that you have a dedicated staff for medical billing services. They should not leave certain encounter data out of a claim. Otherwise, it would end up in the form of claim denials that will come back to haunt you afterward. If a claim is missing a modifier or any other information i.e. pre-authorization, rank as reasons #6 and 9,respectively.  Then a detail-oriented payer will notice omissions and consider such errors as a valid reason to deny a claim.

Therefore, medical billers should ensure that they have filled all of the information in the required areas on claim forms. Make sure that each of the individual claims is double-checked. The claim must not contain any commonly missing fields like patient subscriber numbers. Hence, medical billers should make sure to rectify such errors prior to forwarding them ahead.

2. File Claims In a Timely Manner:

It is the most essential aspect of the reimbursement model. Practitioners should file claims promptly. Although it is the most frustrating task to follow-up with all paid and unpaid claims and filing them before the deadline. Because every payer operates on its own filing schedule.

Providers can easily miss a timing window due to the lack of resources. Practitioners must have sufficient resources and equipment for medical billing services. Adequate resources can help them to track and document each payer’s receipt of claim submissions promptly.

Sometimes, payers deny a claim for unfair reasons. For instance, you file a claim properly but the insurance carrier says they do not receive it before their mentioned deadline. Make sure to hold on payers accountable for their timely receipt of your transactions.

3. Avoid Non-specific Claims:

It is essential to file claims by using medical codes to the highest level of specificity. It is the best approach to reduce claim denials. Especially, it is the best suitable practice for ICD-10 coding implementation. Medical coding specialists must use medical codes for diagnostic procedures to the absolute highest level of specificity. In this way, they will use the greatest number of digits for the chosen code. For example, if it is the seven-digit code and you send a six-digit code then your claim will get back in the form of denial.

Medical billers and coders should dialogue with each other before using the coding schema. Make sure that medical billing staff are well-versed in the nuances of truncated codes. Thus, they can catch them before transmitting the claim forward.

4. Prevent Illegible Claims:

Even if most of the insurance payers accept electronic claims then a few probably are still dependent upon paper and require manual submission. In that case, focusing primarily on electronic claims might cause you to mistakenly overlook the paper forms.Any messy or illegible print claims can become problematic for payers who scan them into their systems upon receipt. Your medical billing staff should always look over claims and confirm that they are readable before sending them off to the payers.

5. Prepare Claims To Meet The Payer’s Standards:

Some payers may be more demanding and sensitive to the claim issues as I have mentioned so far. Although ideally, a medical practitioner sends the perfect claim to the payer then this critique payer would particularly pay attention to the fine details. That’s why, the medical billing team should be cautious about such pickiest payers to elevate the quality of all claims and make them reimbursable. They can also group their transactions by payers to figure out which insurance payer denies the claim more frequently.

6. Did Your Claims get Denied? Take Action Now!

According to MGMA, only 35% of the medical providers appeal denied claims in a timely manner and get paid. Usually, most of the practitioners lag behind the time and can’t appeal claims. As the medical practitioners do not rigorously follow-up with paid and unpaid claims due to the lack of time and resources. However, if practitioners appeal denied claims in the given time window then they can get reimbursements for their services. Therefore, practitioners must acquire sufficient staff and equipment for medical billing services that can help them to appeal denied claims consistently and promptly.


Medical practices should have a proper team of medical billers in place to remove such loopholes that could result in revenue loss. Inspect every single denied claim and remove errors. Task a team of medical billers to handle the denial management system. Otherwise, your practice could be allowing the 4% or more of the revenue you earned to get lost between the cracks.

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