Top 13 Reasons for Claim Denials

From time to time we get calls from clients or their participants because a claim is denied. We came across this report as to what the denial might be and we shared it in this LinkedIn post. Here is a list of the most reported reasons:

• Authorizations — 48%
• Provider eligibility — 42% 
• Code inaccuracies — 42%
• Incorrect modifiers — 37%
• Failure to meet submission deadlines — 35%
• Patient information inaccuracy — 34%
• Missing or inaccurate claim data — 33%
• Not enough staff to keep up — 33%
• Formulary changes — 27%
• Changing policies — 27%
• Procedure changes — 26%
• Improperly bundled services — 22%
• Service not covered — 19%

The most frequently incurred services are basic and simple in nature, and frequently not high dollar amounts. Could this be evidence of too many middlemen making the process for paying for basic needs unnecessarily complex?

In our opinion, costs for health care would go down if we just kept things simple and basic but at this point, things will probably just get more complex due to politics and more and more gimmicks being created to give the impression that a magic process was just invented to make real costs go away.

We’ve been doing this for employers for years and the results have been remarkable. For a no obligation quote simply fill out our census form found at www.ecchic.com/contact.