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Strategies for Avoiding Common Insurance Denials

Insurance Denials

One cannot possibly avoid denials by 100%, but you surely can minimize them to their lowest possible. Millions of medical claims are processed every day in the US and is an essential part of the medical premises. However, thousands of claims are denied on everyday bases too.

Therefore, the question is how one can avoid denied claims. In order to find out the solution we first have to find the problem. Thus, below are some of the main reasons why thousands of claims are denied every day.

Reasons for Claim Denials

There are many reasons why an insurance company may deny a medical claim. Some common reasons include:

  • Incorrect demographic, procedural, or diagnosis codes have proceeded
  • The treatment or procedure is not covered under the policy
  • Services asked are determined to be not medically necessary
  • Pre-authorization or referral from primary care physician was not conducted or assured
  • Did not comply with policy conditions or requirements
  • Adequate documentation or evidence of the medical condition was not provided
  • The policyholder reached the maximum benefit limit of their policy
  • The claim was incorrectly coded or processed resulting in incorrect reimbursement
  • The provider of service is not in-network

These are some of the major and common reasons for claim denials. It is important to understand the specific reasons for a denial in order to address any issues and appeal if possible.

How to Avoid Claim Denials

Here are some of the best practices to avoid claim denials:

  1. Be prepared
  2. Be professional
  3. Be specific
  4. Follow up
  5. Escalate
  6. Use a third party
  7. Be aware of the time limit
  8. Keep your patient informed
  9. Use the correct channel of communication
  10. Know your rights


  1. Be prepared rather

All relevant documentation, such as the denied claim, the patient’s medical records, and any correspondence with the insurance company or provider before reaching out.

  1. Be professional

Use a calm and professional tone when communicating, avoid using confrontational language, and remain respectful throughout the process.

  1. Be specific

Clearly state the reasons for the denied claim provide evidence to support your argument and explain how the claim meets the criteria for coverage under the patient’s insurance plan.

  1. Follow up

Keep track of all communication and follow up with the insurance company or provider to ensure that your claim is being processed in a timely manner.

  1. Escalate

If you are not getting a response or resolution, escalate the issue to a higher-level representative or supervisor.

  1. Use a third party

Consider using a patient advocate or a medical billing professional who has experience communicating with insurance companies and providers. Outsourcing to a professional third-party billing company like claim Solutions can be best for all your needs. They provide medical billing services in Pennsylvania, Texas and including all the states of USA.

  1. Be aware of the time limit

Understand the time limits for appeals and be sure to file them in a timely manner.

  1. Keep your patient informed

Keep your patients informed about the status of their denied claims and the steps you are taking to resolve them.

  1. Use the correct channel of communication

Some insurance companies prefer to communicate through an online portal, while others may require fax or mail. Use the correct method of communication to avoid delays.

  1. Know your rights

Understand the laws and regulations that protect patients and healthcare providers in the event of denied claims.

eClaim Solutions

This can be a tough job for you as a doctor as you do not have expertise in this field. However, you can hire a medical billing specialist but this is also not effective as you have to pay them separately and give them a separate space too which will also come for a price. So, what is the best solution? A third-party billing service like eClaim Solutions (RCM Provider).

Instead of hiring someone, you can outsource to them and streamline the whole process of medical billing. They have all the necessary expertise and equipment that will be needed to avoid all claim denials and manage them to the best of. They have been working in the US for a very long time and know about each and everything regarding medical billing procedures. Apart from that, they also provide urgent care medical billing services. You can contact them through their website or know about other things as well.

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