Tackling Ever Increasing Claim Denials

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Increasing Claim Denials

Recently Kaiser Family Foundation published an analysis of claim denials for various marketplace payers for the year 2020. Under the Affordable Care Act, marketplace payers need to report claims denial data and this analysis used the same data to understand claim denial status. The analysis found that, overall, nearly one out of every five claims submitted for in-network services in 2020 was denied by marketplace payers. However, depending on the payer, average claim denial rates ranged from just 1 percent to 80 percent. Claim denial rates also varied significantly by location, the average claim denial rates were highest in states such as Indiana (29 percent) and Mississippi (29 percent), while rates were just 6 percent in South Dakota and 7 percent in Oregon. This analysis just confirmed ever-increasing claim denials for healthcare providers.

Claim Denial Reason

Payers denied claims for multiple reasons, among denials for in-network services, about 10 percent of denials were for services that lacked prior authorization or referral, 16 percent were for excluded services, and 2 percent were for medical necessity reasons. The majority of claim denials for in-network services 72 percent, were for ‘other’ reasons. While it’s difficult to pinpoint what exactly caused ‘other’ claim denial, these claims might be denied because of administrative or paperwork errors.

This analysis just confirmed ever-increasing claim denials for healthcare providers. This analysis highlighted a whopping 20 percent increase in claim denial rates over the previous five years. The COVID-19 pandemic pushed many hospitals to a ‘denials danger zone’ where denial rates were 10 percent or more of claims. Kaiser Family Foundation also pointed out that their latest numbers also spell trouble for consumers, of which very few challenge denials even when they received in-network services.  Marketplace payers also upheld initial denials in most cases, according to the analysis.

Outsourcing Could be a Solution

As the analysis mentioned, the top reasons for claim denials were lack of prior authorization, excluded services, medical necessity, and administrative or paperwork errors. All these denial reasons could be avoided with assistance from medical billing companies like MedicalBillersandCoders (MBC). Once we receive patient appointment data, we share eligibility and benefits reports for all planned visits. It helps the practice to understand patient insurance coverage, patient liability, and the need for prior authorizations. Payers keep on modifying the list of services that require prior authorization. As the practice owners are busy in patient care, they may not be able to stay updated on prior authorization requirements.