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Medicalbillingstar is one of the leading firm in california which provides medical billing services like medical claim processsing,medical billing and coding,AR follow ups services,EMR support services visit us @http://www.medicalbillingstar.com/ dial 1-888-571-9069
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Top 8 Denial Reasons
Top 8 Denial Reasons
Classification DescriptionAction that is taken by the Medical Billing Star
Claim not on file
(Medical Billing Star responsibility)
In most cases the claims sent out to local insurance companies by paper are the ones that need to be resubmitted as the Insurance companies do not have the initial claims that are sent. billing office ensures that all unpaid claims are called and checked with the respective insurance companies within their filing limits.
Medical Billing Star already follows up on these claims and ensures that the claims are resent within the filing limits
2
Additional Information
(Provider/Patient responsibility)
Insurance companies require separate documentation like, Primary insurance company’s explanation of benefits, the coordination of benefits from the patient, accident details etc .
The billing office ensures that the primary insurance companies EOB is sent out to the secondary Insurance company. All other requests for further information is forwarded to the Patients by statements
3
Patient responsibility
(Patient responsibility)
This is normally the case when patient is billed for the payments as they lack an insurance plan and these claims are kept open until we receive payments from the patients
Medical Billing Star ensures that all payment statements are sent across to the patients in a timely manner
4
Patient not valid
(Provider responsibility)
This is normally the case when the patient has a insurance plan which has termed before his date of service and so the payment statement is sent out to the patient for payment
Medical Billing Star ensures that all payment statements are sent across to the patients with an explanation that their plan has been terminated and that they would have to get back with valid insurance information
5
No Authorization/Referral#
(Provider responsibility)
The provider for certain procedures gets an approval or authorization number from the insurance company before they go ahead. In most cases the authorization number is not mentioned by the provider’s office in the documents sent over to the billing office. Insurance companies deny claims for these certain procedures on these grounds
Medical Billing Star gets back to the provider for information about the authorization number that they should have received. If they get the required info, the claim is resubmitted to the Insurance company
Top Reasons …
Invalid CPT code/ Dx code
(Medicalbillingstar responsibility)
Insurance companies have an approved list of
procedure/diagnosis combinations that they would pay
for. Medical billing star maintains a database of the
approved combinations by different insurance
companies. Our experienced coders ensure that the
highest paying approved combination of procedure and
diagnosis codes are used to ensure maximum payment
Medical billing star already follows up on the
these claims and ensures that CPT/ICD
codes are corrected as per the respective
insurance companies and resubmitted within
the filing limits
Mutually Inclusive
(Medicalbillingstar
responsibility)
Modifiers are required for certain claims to be able to tell
the insurance company that the procedure billed for is a
revaluation based on a previously billed procedure code.
These are reworked by the billing offices and
resubmitted within the filing limits
Medicalbillingstar already follows up on
these claims and ensures that the necessary
modifiers are included and the claim is
resubmitted within the filing limits
Services not covered
(Patient/Insurance company’s responsibility)
This is when the patients insurance does not cover the
procedure performed by the doctor and in most cases
the payment statement is sent out to the Patient
Medicalbillingstar ensures that all payment
statements are sent across to the patients
with an explanation that the services that
were charged to the insurance company are
not covered for their plan
*approximate values, based on 40% of the charged values
Over a 5 month period with our existing clients.
Sl No Categories # of issues Charged amount Amount Received
1 Claim not on file 205 14284.8 5713.9
2 Invalid CPT code/ Dx code 17 4196.8 1678.7
3 Mutually Inclusive 16 1229.3 491.7
4 Additional Information 200 24614.3 9845.7
5 Patient responsibility 96 10438.7 4175.5
6 Services not covered 36 9610.9 3844.3
7 Patient not valid 61 3054.9 1222.0
8 No Authorization/Referral# 49 6407.3 2562.9
680 73837.0 29534.8
Denial Reasons - # of issues
17, 3%
16, 2%
96, 14%
36, 5%
61, 9%
49, 7%
205, 31%
200, 29%
Claim not on file Invalid CPT code/ Dx code Mutually Inclusive Additional Information
Patient responsibility Services not covered Patient not valid No Authorization/Referral#
Denial Reasons – Amount Received
5713.9, 19%
1678.7, 6%
491.7, 2%
4175.5, 14%
3844.3, 13%
1222.0, 4%
2562.9, 9%
9845.7, 33%
Claim not on file Invalid CPT code/ Dx code Mutually Inclusive Additional Information
Patient responsibility Services not covered Patient not valid No Authorization/Referral#
Medicalbillingstar also maintains an internal database of rejected
and underpaid claims of various carriers to serve as an expeditious
source of reference for similar cases in the future. This drastically
cuts down our denial management time-frame and puts the money
where the mouth is, i.e. the physician’s pockets