Medical claim denials continue to be a pain point for many providers. This is especially the case for practice managers who work tirelessly to ensure claims are processed and approved so the patients seeking care can get the treatment they need. Let’s also not forget about the financial ramifications unpaid claims have on a practice’s bottom line.
According to a Kaiser Family Foundation (KFF) report, health insurers on the Affordable Care Act (ACA) marketplace reported 291.6 million in-network claims received for 2021, of which 48.3 million were denied, for an average in-network claims denial rate of 16.6%. With such a high percentage, it’s critical that practices know why their claims were denied. Thankfully, the Centers for Medicare & Medicaid Services (CMS) requires insurers to report the reasons for claims denials. The KFF report went on to reveal, “of in-network claims, about 14% were denied because the claim was for an excluded service, 8% due to lack of preauthorization or referral, and only about 2% based on medical necessity. Most plan-reported denials (77%) were classified as ‘all other reasons.’”
Many reasons could lead to a denial
Medical claims can be denied for a handful of reasons. In many cases it stems from incomplete or even outdated information being entered. Wrong procedure codes can also be the culprit. It’s also common for claims to be denied due to the procedure being deemed not medically necessary or when a prior authorization is required. As a result, sometimes payers deny claims or pay them incorrectly. However, a denial doesn’t mean it’s the end of the road for that claim.
The appeal process can be quick and painless
It’s no secret that submitting timely and “clean” claims that are paid the first time is what every practice manager strives to accomplish. After all, it’s critical to the financial success of their practice. So, when a claim is denied, the next logical step is to appeal. Aside from Medicare, very few payers are able to accept electronic appeals. The appeals process traditionally takes a lot of work to gather supporting documentation and complete payer-specific paperwork. Not to mention printing, stuffing, and licking each envelope!
With Claim.MD, the entire information gathering, printing, and mailing process is streamlined with our easy Appeal Manager. Let us show you how we make the traditionally tedious appeal process a simple one. Sign up for a personalized demonstration to learn more.