From Denial to Approval: Strategies for Conquering 3 Common Medical Billing Challenges

Common Medical Billing Challenges

In the challenging landscape of medical billing, claim denials can disrupt administrative workflows, causing frustration and hindering the efficiency of healthcare providers. A recent survey conducted by the American Hospital Association revealed that 89% of respondents reported an increase in medical billing payment denials. Among them, 51% noted a significant rise.

While it’s impossible to eliminate claim denials entirely, understanding and addressing common denial codes is a pivotal step in managing and reducing their occurrence. In this blog post, we’ll explore three prevalent denial codes and offer insights on how to navigate and rectify them.

#1. CO11 - Mismatched Diagnosis Code

One of the frequently encountered denial codes is CO11, indicating a claim with a diagnosis code that doesn’t align with the provided procedures or services during the appointment. Diagnosis codes define the patient’s medical concern during a doctor visit. Errors in coding, such as typos or incorrect diagnosis codes, often lead to this denial.

Resolution Steps:

  • Check for coding errors and review the patient’s record.
  • Correct any identified errors and resubmit the claim.
  • If no error is found, consider appealing the claim, providing supporting records for the procedure’s medical necessity.

#2. CO15 - Incorrect Authorization Number

CO15 denotes a claim with an incorrect authorization number for a service or procedure. Prior proof levels may be required for coverage of specific procedures or treatments. If this denial occurs, it indicates a hiccup in the authorization process.

Resolution Steps:

  • Review the claim and ensure your team submitted the prior authorization request.
  • Double-check block number 23 on the CMS 1500 form for errors.
  • If prior authorization information is unavailable, attempt to obtain a retro authorization for the claim.

#3. CO16 - Missing Information or Incorrect Modifiers

CO16 is a common denial code resulting from claims with missing information or incorrect modifiers. Reasons for CO16 may include demographic errors, technical errors, invalid Clinical Laboratory Improvement Amendments (CLIA) numbers, or missing Social Security numbers.

Resolution Steps:

  • Pay attention to accompanying remark codes to identify missing information.
  • Correct the identified issues to resubmit the claim successfully.

Learning from Denials for Future Success

While encountering claim denials is inevitable, treating each denial as a learning experience can help identify and correct workflow issues. Becoming familiar with common denial codes empowers healthcare providers to not only correct errors promptly but also to prevent them from recurring.

Remember, it’s not a matter of whether health insurance companies will deny claims, but when and why. By addressing denials proactively, healthcare organizations can enhance their billing processes and minimise disruptions.

If you’re interested in delving deeper into denial codes or need further assistance, reach out to etactics. Don’t forget to like, share, and comment below if you found this information helpful. Stay informed and empower your team to navigate the complexities of dme medical billing service with confidence.