Insurance payment denials – common mistakes in a physician office

Here are the most common mistakes I see made in physician medical practices that result in insurance payment denials; are these common in your office?

Registration Errors  Denials often occur because of an error in the patient registration process; usually from outdated demographic or insurance information. When a patient calls for an appointment, verify insurance coverage and benefits eligibility over the phone. If front office staff can’t gather that information before the appointment, ask for it as soon as the patient arrives and obtain any necessary referrals or authorizations as soon as possible. After verifying eligibility and benefits, a waiver form may be needed so patients understand their financial responsibility if a claim isn’t completely covered. Billing staff should regularly communicate registration errors with the front-office staff, as well as provide reports containing denied claims patterns.

Diagnosis not coded to the highest level of specificity  Your claim may be denied because your providers diagnosis needed to be more specific. Set up electronic prompts into your charge capture system that alert the user when there is a more detailed code available.

Patient’s subscriber number is incorrect or missing  This is caused by staff not entering complete registration information into your practice management system, or not confirming information with the patient. To prevent this denial, set up an alert or flag in your practice management system to ensure that information is filled out before the patient leaves the practice.

About the Author

Reed Tinsley CPA

This article is written by Reed Tinsley, a Houston, TX-based CPA with over 30 years of experience advising physicians and medical practices across Texas and the United States. Reed holds certifications as a Certified Valuation Analyst (CVA), Certified Healthcare Business Consultant (CHBC), and Certified Financial Planner (CFP), specializing exclusively in the healthcare sector. He is a published author, nationally recognized speaker, and trusted advisor to physicians on accounting & tax, practice management, and financial planning. Schedule a Free Consultation.