5 reasons for denials

Denials of claims are a way of life for physicians. In my practice, 15% of claims are denied after first file, and we are electronic. Why? Typically, the denials are the results of admitted mistakes by the insurance companies and, of course, all we need to do is re-submit the claim to get paid--after another 45 days have elapsed. Here are the top 5 reasons that my claims--claims that ultimately get paid on--are denied up front.

1. Referral Issues: Some insurance companies never require referrals while others always require referrals. With these companies, we know the rules and can play by them. However, most insurers are somewhere in between and they have plans within their plans that may or may not need a referral to see a specialist. Yet many of these companies do not publish or notate or list which of these plans within the plan within the plan need referrals. In other words, one can not tell simply by inspecting the member's ID card whether or not a referral is needed and, short of the doctor calling the company on every patient, there is no way for the doctor to know who does and does not need a referral. With some plans, it is up to the patient to know if they need a referral but sometimes the onus of responsibility is on the doctor. So, with these plans, if the patient swares up and down that they don't need a referral when in fact they do, you're out. And, you have no recourse. Tough luck. Of course, from the perspective of the insurance companies, this makes great business sense because the carrier can legally deny payment while simultaneously absolving themselves of any fault in the breakdown of the process. It is beautiful. Fraudulent, but beautiful. And if they do ultimately pay, they at least have had your money earning interest for them over a 6 month period.
2. Missing information: Sometimes, the insurer requests additional information, like an operative note. Of course, these extra items typically are never "received" the first time.
3. Incorrect numbers: Claims can be denied for incorrect NPI, PIN, TIN, PRIS, or member ID numbers. Sometimes a company that has been paying me flawlessly over a several month period mysteriously substitutes a 6 year old, inactive provider ID number for my current ID. Go figure. Other times, the patient's member ID number is entered incorrectly, by a company claims handler. These mistakes can be fixed, but they take time and effort; lots of both.
4. Mis-information: I do male infertility and insurance coverability issues for these patients are anything but straightforward. Since I do this for a living, I have learned the ins-and-outs of determining whether a fertility procedure will be covered. On more than a few occasions, we have determined that a procedure was covered, with authorization numbers and all, only to have it denied because, in fact, the pre-cert person and the claims adjuster were not in agreement. And we got stiffed.
5. Mistake: About 10% of claims are denied simply be mistake: for no good reason. Everything seems OK, everything is in order, everything is place, yet the computer spits out "pay amount: $0.00."

So there you have it. This is the true bane of our collective existences. So many mistakes and so one sided that they can only be intentional.

Hope you enjoyed reading this, because I did not enjoy writing it.