#102 5 Most Common Claim Denials (and How to Fix Them)

In this episode of the NatRevMD Podcast, we uncover the 5 most common claim denials—and exactly how to fix them. From the #1 denial that starts at the front desk to documentation tweaks that save thousands, we’re diving deep into the silent killers of your revenue. 

Discover real-world strategies to avoid modifier mistakes, stay on top of timely filing limits, and even use a simple 30-second script to stop COB issues before they start. 

Subscribe, leave a review, and share to help more practices plug revenue leaks—without the extra stress. 

🔗 Visit www.natrevmd.com for resources like our book, billing course, and services. 

Transcript

Hey, welcome back to the NatRev MD podcast. This week, we are talking all about the common reasons your claims are denied and then a little bit about how to fix them. So as you guys know, denials are the number one reason why ARC tends to creep up, right? And oftentimes that's denials for simple things that if you fixed on the front end, wouldn't be an issue on the backend. And...

Oftentimes when practices come to speak with us and try and figure out a way for us to be able to improve their billing, we're looking at old AR that's past timely filing, which way too late to fix. And oftentimes what I see teams doing is the billing teams in previous roles get behind. The claims build up, they're sending the claim issues to the practice to help get answers. Maybe they're sending an email, maybe they're doing them on phone calls.

but there's no real tracking mechanism to say, hey, I still haven't gotten a response back for these denials. Is there a code to change? Is there eligibility? Is there coordination of benefit issues? And so what ends up getting lost is the solution to fix these, or there's claims that you keep resubmitting with the same exact information hoping for a different response. Obviously that's not going to happen. So today we're gonna talk all about the top five things that we see.

as reasons for denials and how we typically fix them in our own billing practice. If you guys are new to the podcast, please check us out at natrevmd.com. That's N-A-T-R-E-V-M-D.com. We've got a podcast. Obviously you're here listening. We've got a book. We've got a billing course as well. All the things that are available to you so that we can help increase awareness and knowledge around the billing process. All right, missing.

or reason number one for denied claims. And this is something that's so basic that you're gonna go, well, duh. And that is missing or incorrect patient information. Number one reason that we see denials across all subspecialties is just really incorrect patient information. And this can be incorrect information on the patient's name, date of birth, insurance subscriber card, all of that is just simple stuff that we see commonly.

And so some practices that we've worked with can sometimes have over 10 % denial rates. And when we started getting in there and reviewing those claims, we found that the majority were due to incorrect insurance ID numbers or information. Sometimes it's as simple as a single digit was being left off or the patient's name was not matching. Again, these were small mistakes, but they were big impacts. And again, back to what I said previously about how practices sometimes

can have an outsourced billing team and the outsourced billing team doesn't do eligibility, which is common for outsourced billing teams and common for billing teams in general. The eligibility is done at the front office, but then they're waiting for information. They aren't able to get it. The practice gets behind in responding to the billing errors. And so it just turmoils and then we've got AR that builds up into six, seven figures. So how do we fix this? At every visit, your front desk should be, of course, verifying

insurance information. Ideally, this should happen when you're scheduling the patient appointment. So you're scheduling the patient appointment, you're getting the insurance information, you're checking eligibility, and when the patient comes in, you're asking them, has anything changed, ask to see the card, get front and back snapshots if something has changed, run real-time eligibility checks if anything has changed before they leave the building, and obviously, they're actually now

software checks, are things you can automate, there's AI, all kinds of things that can be done on the front end in order to make this work really well. We're actually trialing and working with some AI companies that are connected to many different payers trying to see if we can solve for this problem for our practices. And again, you guys will be the first to hear when we do come up with the solution, we're just kind of trialing some AI technologies that are out there to again, solve this problem. It's very manual right now.

It can be less manual depending on your PM software, the software that you have. It can be less manual depending on the clearinghouse you use. But again, please use as much as you can software that you have in order to enable this. Please make sure that any eligibility failures or things that aren't going through as insured are getting addressed before the patient is seen. And I will tell you that for those practices that do have high denials, this is the number one reason.

for denial issues. Now, reason number two for denied claims, again, we're talking about denied claims, is lack of medical necessity. Now, of course, just because the visit was necessary to you clinically doesn't mean that the payroll agree. Annoying, awful, yes, reality, yes. So an example of this is say there was a family practice physician who saw

consistent denials for 99214s. And they were doing routine hypertension checks. When the notes were reviewed, the note was too brief, right? It was missing documentation that really supported the complexity of a moderately complex visit. So the visits either should have had more documentation or they should have been down coded to maybe a 99213. And the payers caught on, right? They were seeing a ton of 99214s, they're asking for medical records, and then they're denying them.

Another example of this is where you say doing a procedure and you're submitting it with ICD-10s that don't match up to the CPT that was submitted. And for Medicare, this is really easy to confirm, right? Because the CPTs and the ICD-10s that claim for medical necessity are all online. There's like this huge, massive spreadsheet that you can download and you can go and search up your CPTs. You can go and look and see what ICD-10s meet medical necessity for those CPTs and it's all there for you.

Not quite as easy for commercial payers, but I like to see if Medicare rules are at least reviewed and it meets Medicare medical necessity. Sometimes that will meet medical necessity for commercial payers, but it's a good place to start if you've never even looked. So some fixes around that are to make sure that you're really, really beefing up your documentation, especially if you're billing out those higher level E codes. And you can even use EHR templates.

But really making sure that you are understanding the level of documentation needed for this EPT code. You got to tell the story. I know it's frustrating. I know we should be able to just do what we want to do because we're the physician and we shouldn't have to document it. But unfortunately, that's just not the way it is with insurance. So we've really got to make sure that we're telling that story. We're talking about the diagnosis. We're talking about the things that we've done. We're talking about what we've reviewed, the lab tests we've done, the people we've talked to, et cetera.

so that you can really explain the level of complexity for the CPTs that you're building. And of course, review those payer policies. Specifically, Medicare has some really clear ones. Sometimes you can find others for commercial payers. If you have CPTs that are consistently denying, work with your billing team to go through those and understand why that may be, or have a certified coder go through those audits. Simple provider education.

Truly can dramatically reduce these denials, but you gotta know what's being denied and why, and then go and fix them. Number three, reason number three for common denials. So something that we see in our practice is modifier errors. Modifiers can be your best friend or your worst enemy. Now we try and catch and scrub claims for modifier issues upfront, but oftentimes if a coder isn't going through and reading your notes, sometimes you can miss the modifier.

errors or if, you know, for most of our practices we're not coding for them, the physicians are coding. So having the right modifiers on there is really important. Or misuse of a modifier. So say you're giving codes to your billers and you're adding on a 25 modifier, but it's not truly medically necessary for significant and separately identifiable for that modifier 25, then you're going to potentially get a denial. And there's a lot of focus right now on modifier 25.

when it comes to using it inappropriately. And again, that definition of modifier 25 is it's gotta be separate and significantly identifiable, and you've gotta have the documentation to back that up, right? So say you're seeing, having a well woman exam, and you also notice, you know, a small issue. And maybe it's as small as, okay, the patient says they have, let's see, heavy bleeding.

but you don't really talk about it, you don't really do anything about it, then that's not gonna qualify for a modifier 25. But say you've got a patient well woman exam and they've got a breast lump and you sit, palpate the breast lump, you then sit with the patient, you do counseling, you do mammogram, ordering, you review family history, you get a plan of action in place, that is gonna qualify for a modifier 25. So you've gotta really think through.

What modifier are you using? Do you really understand the modifier definition and what qualifies in order for the documentation to meet necessity? And so really, really important to follow up with this. I can't tell you how many denials we'll see with that modifier 25 and those being denied because the documentation isn't there or the level of

clinical necessity isn't there. You build that modifier 25 for a very minor thing that you didn't do a true E on. So really, really make sure you understand, okay, if you use three or four modifiers, I most practices don't have a ton of modifiers that they use, really understand those modifiers and understand the level of documentation that you need. There are oftentimes modifier cheat sheets that can be used by the payers.

And again, audit those most frequently used modifiers, 25, 59, 24, 76. Sit down with your providers, sit down with your billers and make sure that you really understand the modifiers you need to be using and when to use them and that it's got to be justified in the documentation. And figure out who's throwing those modifiers on, right? So for us, for our billing company, we're oftentimes scrubbing the claims, you know, trying to throw in the right modifier, but we're also not coding the the cases upfront.

That's what most of our physicians are doing, at least for most of our practices. So it's about working together and making sure that together you're really understanding what's the best process for your practice. All right, number four. This is the most painful one ever. Timely filing limits. It hurts because you can't appeal it. Once tiling filing window is missed, you are done.

We've had a client, we've had multiple clients where we've taken on the old AR and we're trying to work those old claims and we're getting lots of timely filing denials or where we have physicians that really struggle to get their cases turned in timely and those hit timely filing. And I can't tell you enough that this is the number one thing you should not see as timely filing issues. Now Medicare has 12 months.

12 months, but we have many commercial payers that only allow 90 days. And that lost revenue is the most painful of any denial that I see. So again, know your payers, timely filing limits, sign it cases on time, and again, have some sort of tracking system with your billing team to allow for those regular check-ins on claims that are not getting paid.

that are something that we need to resolve, right? So whether that's on the practice to help the billing team, you know, submit a new code, get a new eligibility or get a new insurance information, whatever the claims issue is, we need to come to a solution. Sometimes this is very hard and there's a lot of back and forth. This is one of the most manual things is working AR. And so there has to be a solid process in place. Again, for us, we do...

these issue trackers and that is the way that we keep on top of the claims. right, reason number five. Oh, this one's painful. Coordination of benefits. I hate coordination of benefits. They're the most painful thing for a practice. So let's talk about what this is. So if a patient has multiple insurances or recently changed coverage, your claim may get denied until this coordination of benefits is sorted out, meaning who's responsible for paying the claim.

So say a patient switched from either having a commercial insurance to Medicaid or vice versa, but the front desk only has the old insurance information, not the new information. So then you've got visits going to the wrong payer and then you don't get those denials for 30 days. And if you're not careful and you don't have a good way to then say, no, we've got the wrong insurance, need the right insurance from the practice in order to build a correct insurance, you could hit timely filing.

Again, hopefully not, you've got an issue tracker, you've got something where it's a good way for you to bounce back and forth with your billing team. But again, gotta have at every single visit asking patients if anything has changed with their insurance. Have they changed jobs? Have they applied for Medicaid? Anything that could trigger a change in insurance. This is a very common thing for some practices and for others, they don't deal with coordination benefits often. Sometimes it's the patient mix, but these are very, very painful.

Use eligibility tools that check for multiple coverages. This is just another option and tool in your tool belt. And if you are getting frequent COB denials, really got to have a front office script to dig in deeper at check-in if they could have multiple insurances. All right, so in closing, denials are never going to go away. So if you're expecting denials to be 0%, it's just not possible. But you can prevent a large number of your denials.

by having your eligibility checked up front, really learning from your past denials, documenting clearly, and then working with your billing team to understand what those denials are. So we include our denial reports for most of our practices where it's possible. We have some clearing houses that don't have a great way to provide that, so it's very manual, but it is important to have some information around your denials, your rejections, so that you can do better next time, right? Learn from our mistakes so that we can do better in the future.

If this podcast has been helpful to you, we'd love for you to share it with others. It helps us help other practices and help healthcare team members get paid for the work that you're doing. As always, check us out at natrevmd.com, N-A-T-R-E-V-M-D.com. We do have a self-assessment on the homepage that you can go and fill in and get a response back on how things are going for your own team. Thanks for tuning in and we'll talk to you next time.