Manage Insurance Claim Denials More Effectively

Candace Lewis, Director, Revenue Cycle Management Revenue Cycle Management (RCM)

claim denials

Resolving insurance claim denials can be a time-consuming process that often gets placed at the bottom of the to-do list. Below are two common claim denials, how to resolve them, and how to avoid them in the future.

2 Common Insurance Claim Denials

Patient not Eligible

This claim denial is a result of the front desk staff not getting the most current insurance information from the patient and/or not verifying eligibility prior to the patient visit.

  • Resolve: Once this claim denial is received, the billing staff will need to obtain current insurance information. This can be done by checking payer websites or calling the patient to verify current policies. Once active policies are received, the office should enter the updated information in the patient demographics and inactivate the insurance that is no longer valid. This will ensure that next time the patient is seen in the office the active insurance will be used.
  • Avoid: To reduce this claim denial in the future, someone should be assigned the responsibility to verify eligibility before a patient is seen. Most electronic medical records (EMRs) can verify insurance automatically. The resulting report lists ineligible patients who should be reviewed before the date of service. This enables patients to be notified before they arrive to the office that the insurance on file is not active.

No Authorization on File

This claim denial is the result of a prior authorization not being obtained for a service that is required.

  • Resolve: When this claim denial is received, the biller should contact the insurance company to obtain a retro authorization. Once the retro authorization is received, the service should be rebilled with the authorization number.
  • Avoid: To reduce this claim denial in the future, authorizations should be obtained before the service is rendered to ensure the insurance company will give an authorization for the procedure. 

Medical Advantage Revenue Cycle Management Services offers workflow assessment, eClincialWorks practice management training, medical record audits, billing audits and credentialing services.  Learn more about our Revenue Cycle Management Support Services.