Has Your Claim Been Denied?
Greenline Revenue Services is kicking off the Healthcare Claim Denial Reason Series for 2025! We are breaking down some of the top reasons for denials and how to correct it to increase your practice’s revenue!
Has your practice faced denials for necessity or authorizations?
This month, we are digging into some of the leading denial reasons and how to fix them!
Coverage
Medical necessity is the fundamental support that enables claims to be successfully paid. It is crucial for providers to ensure that the services reported are consistently:
Covered
Rendered
Documented
One of the critical initial steps taken before a patient presents for care is to thoroughly verify their insurance coverage. Surprisingly, many claims are denied simply due to the omission of this essential step. By diligently verifying the payor's coverage of the patient and the specific procedure being performed, the likelihood of a claim denial can be reduced drastically.
Prior authorization requirements represent another significant reason for conducting thorough coverage verification. Payors have the authority to deny claims based on a lack of prior authorization, and some will not retroactively grant this authorization for services that have already been rendered. It is essential to be aware that payors frequently make changes to their policies, both annually and throughout the year. Therefore, it is important to ensure that the most up-to-date policy information is maintained on file. The months of March and April are particularly busy times for policy updates, including additions, deletions, and clarifications.
Furthermore, it is imperative that the services provided are accurately rendered. The days of frivolously filing incorrect claims in hopes of a quick and easy payday are long gone. With the advancement of technology, there have also been significant increases in regulatory laws. There is now a zero-tolerance policy for fraudulent claims. Providers must ensure that what is being billed has indeed been performed. If it is not documented properly, it did not happen!
This leads us to the critical importance of documentation. Providers must ensure that all patient encounters are meticulously documented, accurate, and duly signed. If a report has not been signed by the physician, the claim cannot be billed, which can result in increased A/R days, decreased revenue for the reporting period, and potential timely filing denials. A claim denial translates to lost revenue and should be avoided at all costs to maintain financial stability.
2. Medically Unnecessary
Most payors, including government and private insurers, provide a comprehensive list of procedures that are categorized as medically unnecessary. For example, Medicare outlines a list in their publication, the Medical Learning Network (MLN), which includes items such as:
Services that could be effectively provided in a different, more appropriate setting
Inpatient stays that exceed the allowable number of days as determined by the Centers for Medicare & Medicaid Services (CMS)
Assisted suicide
And several other specific treatments
Many insurance payors diligently follow the CMS guidelines that pertain to billing practices and the payment of claims. To maintain compliance, it is essential that the practice regularly reviews their fee schedules, updates policies where necessary, and ensures that the processes and procedures of each member within the facility reflect accurate, ethical, and legal standards of practice.
There are circumstances in which services deemed unnecessary can be thoroughly reviewed and potentially overturned based on comprehensive documentation from the treating provider. If the provider has the opportunity to dispute this type of claim denial and is prepared to substantiate the necessity of the treatment provided, he or she should take proactive steps to do so!
Greenline Revenue Services is dedicated to helping healthcare practices reduce denial reasons and improve operations. Our approach aims to boost timely revenue collection. By working with us, your facility can implement customized strategies to tackle specific revenue cycle challenges. We invite you to complete the ‘Contact Us’ form to connect with one of our experts, who will help enhance your practice's financial performance.
