Coding and Billing

How to Avoid 3 Common Denied Claims in Your Practice

By John W. McCormick, OD

Jan. 13, 2016

Managing your claims process can be a challenge for any eyecare practice. You need the right staff who can troubleshoot, ask the right questions, and are familiar with the ins and outs of all the different nuances of the insurance world. Even with the best staff, the claims process will get messy, and denials are something that every practice has to learn to avoid.

Though your practice may have a practice management system and clearinghouse solution, you are still going to be hit with denials. This article is aimed to help you learn how to prevent three types of common denials, and how to use your clearinghouse, or practice management solution, to its best ability.

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Reason for Claim Denial #1:  Submitting Duplicate Claims

Why this happens:
In my practice, duplicate claims are the most common reason for denials. Duplicates happen when two or more submitted claims include repeated information about patient demographics, provider, date of service, and billing codes. For us, it happens more often when our biller finds an unpaid claim in the system and assumes that it hasn’t been processed. With the intention of fixing the problem, the claim gets filed again.

What you can do to make sure it doesn’t happen:
There are several reasons why a claim might be unpaid in the system. A processed claim could have gone toward a deductible, or could have been denied. Your biller may not realize duplicate claims are the cause of denials. Instruct the biller to investigate the reason for an unpaid claim before automatically submitting the claim again.

What you should do when it does happen:
As I mentioned before, find out why the claim isn’t paid in the first place. Was it rejected by the clearinghouse, or carrier, for one reason or another, or actually denied? Pull up the EOB, or Electronic Remittance Advice ( a document supplied by the insurance payer that provides notice of and reasons for payment, adjustment, denial and/or uncovered charges of a medical claim), and look for the denial reason so you can fix the claim. In our practice, since we use a clearinghouse, we can correct the claim electronically and use the re-submission feature to quickly get it updated.

Reason for Claim Denial #2: Incorrect Information

Why this happens:
Another common reason for claim denials in my practice is caused by incorrect patient information. A denial due to incorrect patient information can be caused by a data entry error, or a patient providing your staff, or the insurance company, incorrect information. In this case, we will fix incorrect information from data entry.
What you can do to make sure it doesn’t happen:
Mistakes happen, and data entry errors are bound to occur. Data entry errors by your staff can occur when recording important insurance information like policy numbers or demographics. When a patient comes in for their appointment, make sure your staff is double checking for patient name, date of birth, responsible party, vision policy and numbers, and medical policy and numbers. The best way is to copy their insurance card and make it part of the patient record.
Pulling benefits is a good way to ensure you have the most updated information about their coverage plan.
What you should do when it does happen:
In this case, your biller will need to follow up with the patient to gather the correct information. Or, if you have a photocopy of the patient’s insurance card you can start there to look for where the error occurred.

Reason for Claim Denial #3: Coverage Termination

Why this happens:
Coverage termination denials are usually caused by a patient getting a new policy, dropping the plan, or failing to make a monthly payment resulting in them not being covered during the time of their appointment.
This type of denial has happened in my practice because even though our biller checked a patient’s policy when they scheduled their appointment in July, between scheduling the appointment, and the day of the actual appointment, the patient missed an insurance payment, or switched insurances, and is no longer covered by the insurance during the time of the appointment.
What you can do to make sure it doesn’t happen:
Pay attention to plans that are renewed monthly, such as Medicaid, and be sure to check eligibility at the start of the same month at the patient appointment.
Let’s use Medicaid as an example. Medicaid plans become active at the beginning of the month, so if you check for eligibility at the beginning of the month of the scheduled appointment you should be in good shape. While your biller should be in the habit of checking for eligibility ahead of time, make sure it’s noted on plans like Medicaid to check again when it’s closer to the appointment so you can ensure payments and information are up to date during the month of the appointment.
What you should do when it does happen:
Having an experienced biller who is familiar with the types of insurances that are paid through a monthly premium, or are renewed monthly, can help you avoid this type of denial, but there are still times a plan will slip through the cracks and burn you.
If you get a denial from coverage termination, it’s time to reach out to the patient. Chances are, the patient is covered under a new or different Medicaid plan this month, or they switched to a new private plan and just need to update you with the correct information. If a friendly attempt at collecting the information doesn’t succeed you can opt to bill the patient as a way to encourage them to give you a call and provide the right information to clear up the claim.

John W. McCormick, OD, is the owner of McCormick Vision Source in Austin, Tx. To contact him:



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