Corporate Compliance

Why are claims denied?

Healthcare Auditing Weekly, February 15, 2005

An audit of your organization's billing system will help to recoup lost dollars from claims denials and eliminate future denials. Before you begin though, you've got to understand why denials occur. Here a few reasons:

  • Insurance verifiers may have failed to closely read effective dates of coverage

  • Case managers may have forgotten to obtain authorization for a portion of the services provided

  • Departments may have entered charges on the wrong account

  • Medical record personnel may have attached the wrong Health Care Finance Administration (HCFA) Common Procedure Coding System code

  • Patient financial services' 72-hour rule editor may not be functioning correctly

    Look for next week's issue when we discuss how to identify unfair denials.

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