denials in medical billing

7 Types of Medical Billing Denials and Practical Tips to Avoid Them

Use this list of medical billing denials and remedies for emergency physician groups. This list will help you to increase the percentage of clean claims you submit.

For your emergency medicine (EM) group, medical billing denials are more than stressful and annoying. They reduce the productivity and efficiency of your emergency room while also costing you money.

Denial management involves:

  • Determine the reason of rejected medical claims
  • Choose the most effective strategy to reduce denial claim rate
  • Put tactics into practice to raise your clean claims
  • Generate revenue

Here we will discuss some reasons why you should start worrying about your EM group’s denial rate.

What Matters Most in Medical Billing Denial and Solutions

According to industry norms, hospitals’ emergency medicine billing denial rates typically range from 2% to 5%.

However, a Government Accountability Office (GAO) investigation reveals that a startling 25% of claims are rejected.

Medical denials are of two types:

  • Hard denial.
  • Soft denial.

Hard denials are irreversible and cannot be revised. Your organisation must write these as lost revenue. 

Whereas soft denials can be resolved and repaid if the providers revise the claim or send more evidence of the service they provided.

Many independent emergency medicine practices lack the resources—staff, resources, and time—to rewrite shady claims. Thus, between 50 and 65 percent of denials remain unpaid.

An average of $25 per claim spent on each rework. It will cost you $2,500 per month to update 100 claims to make the claims legitimate.

Yet, practices who decide to write off their denials rather than resolve them typically lose between 1% and 5% of their net patient revenue.

This loss can total thousands of dollars, depending on the size of your practice. After all, $10,000 is still one percent of $1 million in income.

That much money shouldn’t be left on the table in any practice.

The good news is that reworking EM groups’ claims results in a success rate of over 60%. As a result, your practice will receive much-needed financial support.

Medical billing denials are inevitable. However, you can stop the most frequent ones.

List of Denials In Medical Billing You May Avoid

Do you know how many denials in medical billing? No worries, we will let you know with the help of this list of denials in medical billing. Keep reading!

  • Lack Of Information

An inaccurate claim will almost always be rejected. But, even when a claim form is completely filled out, it could still be missing some details. There are intricate regulations that insurance companies have for doctors and insureds. You may need to record –

  • When a patient is referred for a particular service,
  • That an alternative therapy was first explored.
  • Indicates that the patient had tests done for a particular medical problem.

There is a chance of denial without explicit proof that the procedure is covered by the plan and medically required.

  • Billing An Incorrect Company

As a result of price and provider changes, an increasing number of consumers switch health insurers each year. Thus, more and more bills are being sent to the wrong company.

Patients’ insurers may change from year to year. Examine the coverage and service dates carefully to ensure the correct company receives the bill.

  • Patient Responsibilities

A rejection that is categorised as a patient’s duty could be due to one of several things. The denial should often state the exact contractual issue that gave rise to the refusal. Among the most typical are:

  • The patient’s deductible was not yet met.
  • The patient had got a recommendation.
  • The treatment is not covered.
  • The information required to check the claim’ coverage is missing.
  • Another insurer covers the service. Ask the patient whether they have a back-up plan and find out.

  • Mistakes In The Transcription.

There is a high risk of a typo. The handwriting of doctors is typically poor. Medical claims cannot accept this type of data submission. 

  • If the spelling of the patient’s name is incorrect.
  • Uncorrected date of birth entry
  • When the billing code claim is false,

It is impossible to accept the claims in any of these situations. 

  • Clashing Claims

The service time for two claims that seem to overlap is known as overlapping claims.

Duplicate billing is the opposite of these denials. It might happen when a patient receives care from many providers.

  • Duplicate Billing

Duplicate billing is a huge problem in medical billing services. More and more medical offices use automated billing services for payments.

  • Contractual Commitment

With medical billing companies, providers have their own contracts. You agree to follow specific billing criteria when you accept these conditions.

A medical billing denial indicates that you haven’t cleared one of the insurer’s hurdles. Typical problems include:

  • Failure to submit the claim on time.
  • The claim has already been settled.
  • The provided claim does not confirm the need for the service.
  • If the service provider offers too many services.
  • The covered service was rendered during a period when the supplier lacked the necessary certification.

Strategies for Preventing Denials in Medical Billing

  • Discover The Type Of Rejection You Experience Most Frequently.

Nowadays, intuitive systems can monitor, quantify, and classify data about denial trends by:

  • Physician
  • Department
  • Techniques and offerings
  • Payers as well as insurance firms

Incorrect codes may be the cause if you notice a rise in denials for non-covered treatments. These insightful statistics will highlight the key areas where your team should concentrate in order to achieve quantifiable success.

  • Always Keep An Eye On Your Clean Claims Ratio And Give Your Input.

Clean claims are always paid out right away. The definition of a “dirty claim” is

  • Whatever is rejected.
  • Filed multiple times.
  • Contains mistakes.
  • It is possible to avoid a denial, etc.

You’ll be able to give feedback to your personnel once you start keeping track of denials. With that, companies may make improvements and reduce denials.

  • Choosing The Best Claims Management Solution.

Most complex claim denials include coding mistakes.

Choose claims management software that provides you with current, accurate claims statistics. Furthermore, CMS has intelligence features that can identify errors before claims are submitted and rejected.

Moreover, deadline reminders will stop claims from falling through the cracks and going out of date.

Yet, if all of this seems like a lot for your independent EM staff to handle, you don’t have to do it alone.

Final Thoughts

While the rules and regulations are continually changing, it is difficult to maintain a low denial rate. 

Hire a medical billing company in USA and delegate this job to professionals.

It will be the right choice you’ve ever made for your team to work with Virtual Oplossing Healthcare.


✅ What are the medical billing denials?

Medical billing denials refer to claims that have been processed and then rejected by payers. In contrast, a claim is rejected when it is sent to a payer with incomplete or inaccurate data or coding. Many different billing and coding problems can result in claim rejections.

✅ What kinds of denials are there?

Medical billing denials come in two forms: hard and soft.

Hard denials are irrevocable, as their name suggests, and can lead to lost or written-off revenue.

Soft denials, on the other hand, are temporary and may be overturned if the provider amends the claim or gives further details.

✅ Claims management software – how can they help?

With Claims management software, you can get up-to-date, precise claims statistics. Moreover, CMS has intelligence tools that can spot mistakes before claims are submitted and denied.

✅ What does the list of denials in medical billing include?

The list of denials in medical billing includes many aspects. Some of those are:

  • Missing Information
  • Typo Errors
  • Duplicate Claims
  • Overlapping Claims
  • Patient Obligations
  • Coding Issues

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