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My Claim Was Rejected. Now What?

A claim rejection is when a claim doesn't actually arrive at the insurance company. A claim rejection occurs when there's a demographic error or an insurance error that the clearing house (the company that operates as an intermediary between the insurance company and your electronic health record company) identifies and lets you know that there is an error with the claim. This kind of screening is known as scrubbing a claim. This is an incredibly important process because it helps you identify errors faster and receive reimbursement without having to wait for a denial.

A rejection can be quite unsettling firstly because the term rejection is a harsh term, but also because it means that there is an error that you have to fix. This can take time and valuable money that you may or may not have to fix an error that could have been prevented.

In this blog we want to walk through the steps that are necessary to fix the claim rejection and get paid for your services. Claim rejections are normal, and a calm level head will make dealing with a claim rejection much easier. Claim rejections occur for a wide range of reasons and are able to be fixed. The thing to keep in mind with this process is that communication with your client is critical. You will need their cooperation in order to fix the claim rejection.

Identify the Reason for Rejection

The first thing to do when you have a claim rejection is to identify the rejection. Typically there's a notification within your electronic health record system that alerts you to the rejection. Once you find the rejection report you'll find an explanation for why the claim was rejected. Once you find the reason you'll probably find one of the following reasons; The date of birth for the client is wrong, the insurance is invalid, duplicate date of service, or even that the name of the client is incorrect. Keep in mind that the slightest error can cause a claim rejection and therefore cause problems with the claim process.

Double Check Your Client Information

Once you've identified the claim rejection and the claim is actually the reason, the next step would be to review all of the client’s information. You'll want to look at their insurance car and the address that the client provided. Once you have all of that information you want to check it against the information that was submitted on the claim. Most of the time you are going to be able to find the issue and fix it internally without having to check with your client or with the insurance company. Typos happen, whether it be during the claim creation process, or when patient data is entered into your EHR system. Once you've identified the error you can fix the claim within your electronic health system and resubmit the claim. The important part here will be making sure that the claim actually goes through the system and does not reject again. If the claim is rejected a second (or even third) time you'll have to follow up once more.

Develop Processes for Continued Success

The last thing that you will want to do following a claim rejection is to make sure that subsequent claims do not reject. One of the problems that billers run into is that a rejection is fixed but then something changes with the patient information and claims get rejected again. We want to make sure that all the information that the client gave you will be sufficient for the insurance company on subsequent claim submissions.

One of the ways that you can ensure that this happens is by conducting regular insurance verifications on your patients information. If you're able to ensure quality information within your electronic health record system you will be able to have a smoother time billing insurance.

Obviously the goal is to not have claims get rejected but it is part of the process of billing insurance and working with people. People don't always give the most accurate information and their situation changes all the time. You will have to build in processes that are flexible to a changing world and allow for mistakes like that to happen.

If you are experiencing regular claim rejections then there might be a credentialing issue and we will be able to help diagnose that issue. Feel free to reach out to us through our website for further assistance with billing issues that you are experiencing.

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