Why Medical Billing Claims Get Denied?

There are a number of reasons that your medical billing claims could be getting kicked back. Next time you have a medical billing claim kicked back, carefully check it to see why it was returned. Finding out why your medical billing claims were refused will sometimes uncover an unhealthy pattern in your office such as not keeping up with the changes to the CPT codes.

And that’s our number one reason, usage of outdated or improper codes. The CPT updates a number of times a year and keeping up with those changes can be difficult. However, if you don’t use the most current coding the carriers are well within their rights partially pay a claim or reject it. A code that was perfect two months ago may have been retired or split into other more defined codings. The only way to know is to keep up with the changes to the CPT codes.

Lack of documentation or partial documentation is a big one. The carrier simply won’t pay if you can’t show through documentation why the procedure you’re asking for reimbursement for was necessary in the first place. Make sure your documentation that accompanies your medical billing claims is accurate and detailed.

Improperly filled forms is another reason your medical billing claim may be rejected. Make sure the superform is filled out completely and accurately.

If your staff is tired of keeping up with the changes to the medical billing industry, it may be time to consider outsourcing to a third party partner that does nothing but your medical billing claims and keeps up with the changes to the codes.

View all Articles by: Kathryn E, CCS-P - Retired