Corporate Compliance

Tip: Why are claims denied?

Compliance Monitor, February 23, 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 Common Procedure Coding System code

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

    The above tip is an excerpt from the book "Hospital Auditing and Monitoring: Sample Programs for Key Risk Areas." Copyright 2004 by HCPro, Inc. This book is a step-by-step, practical manual that offers sample audit programs for the most troublesome areas that a hospital must audit. The binder and CD-ROM are filled with actual audit programs used by auditors and compliance officers in the field. Click here for more information or to order your copy today.

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