The Three Main Reasons Claims Could Get Denied – And How to Avoid Them

As an agency owner, there’s nothing more frustrating than having a claim denied, that you thought would get you paid! Not only does it mean a delay in payment, but it also requires you to go through a potentially grueling process. That’s why it’s essential to understand the most common reasons claims get denied – and how you can avoid them. In this blog post, we’ll be discussing the three main reasons that claims get denied, and the steps you can take to steer clear of these issues. 

1. Failure to Verify Visits 

One of the most commonly cited reasons for denied claims is also one of the most easily avoidable: failure to verify visits. This means that when you create the claim, you haven’t gone through the process of checking whether all visits have been verified in ( Your EVV provider like Sandata or Tellus.). This is a critical step because if a visit hasn’t been verified, the payer will not reimburse you for it. To avoid this issue, it’s crucial to check your provider (Your EVV  provider like Sandata or  Tellus) thoroughly and frequently.  

An example of this in Indiana is as follows:  

It is Thursday. You submit your visits for Monday through Friday even though Friday has not happened yet, and is not verified! Therefore, the entire claim is denied! Even Monday through Thursday, and you get paid, well, nothing. Yikes!  

Make sure you’re keeping up to date with all verified visits so that you can submit claims that will ultimately get accepted. 

2. Counting Units Incorrectly 

Another common reason that claims get denied is due to incorrect unit counts. This is typically due to simple math errors, but it can also result from using the wrong date range or failing to do a discount double-check on the submitted claim. To avoid this pitfall, it’s essential to utilize GEOH to calculate units accurately. Do not use Sandata for this process, as it’s not always reliable, because it uses an incorrect unit rounding, costing you more units than you need to complete your billing.  

Double-check your math and the date range you’re using to be sure that your claims will be accepted. Seriously, double-check your math! This is the MOST common error that claims are denied, and it is completely avoidable.  

3. Missing or Incorrect Information 

Finally, the third major reason claims get denied is because of missing or incorrect information. This could mean anything from a wrong diagnosis code, to missing EVV data. It’s essential to double-check your claims for completeness and accuracy before submitting them to the payer. Make sure that you’ve included all necessary information and that it’s correct. Any errors or omissions could result in your claim getting denied, so take the time to be thorough. 

  While there are many reasons a claim could get denied, these are the three most common. The good news is that each of these pitfalls is easily avoidable. By verifying visits, counting units accurately, and ensuring you’ve included all necessary information, you can help ensure that your claims get accepted and paid on time. As an agency owner, proactive attention to detail is critical to your success and financial stability. Plus, avoiding denied claims can save you valuable time and money. So, put in the effort now and reap the rewards later. Stay diligent, keep double-checking, and don’t let these common errors catch you!