No matter how well you run your practice, you will at some point or other experience rejected claims. Did you know that even if rejected claims are running at as little as 4% of total claim volume, that will still equate to R48 000 a year for the average practice*?
This emerges from a study we’ve done of more than 6 million claims sent between January and December 2015. Although this cash may still be recovered by resubmitting the claim, it’s worth understanding why medical aids reject claims so that you can improve your cashflow and reduce your risk of bad debt. From the data we’ve analysed, here are the main reasons why claims are rejected – and what you can do to avoid it.
1. The patient claim information is incorrect or has changed
When a patient changes his/her medical-aid plan, the cover may lapse. Even without changing plans, benefits may be exhausted without the patient realising it – in both scenarios, the claim is rejected. Capturing incorrect information, or making keyboard errors, also results in the claim being rejected. Here are the most common data errors:
- Name spelt incorrectly
- Date of birth doesn’t match
- Patient number missing or invalid
- Medical aid number missing or invalid
Solution: Perform a patient benefit check before the consultation. You’ll then see if the patient’s medical aid details agree with the information you have captured.
2. Stale claim – you’ve waited too long to send the claim
Most schemes give you 120 days to send a claim; after that, it might get rejected.
Solution: Send claims in real-time (Send Now) while the patient is still at the practice. This gives you a real-time response, and also allows you to deal upfront with any amounts that may be outstanding.
3. Incorrect or missing codes
If diagnostic or procedure codes are missing, incomplete, invalid, or do not correspond with the treatment, the claim will be rejected.
Solution: Use pre-populated templates to send your claims; this will ensure you have both the correct codes and the required lines.
4. Duplicate claim
You send a claim twice, which triggers a rejection. This often happens when:
- practice processes do not incorporate checking and separating of patient files, which leads to confusion as to what was sen
- practice-management applications are upgraded, and for some reason the technician re-sends an old claim.
Solution: Check proof-of-claim submission. If your claim was sent and you still have no response, chase it up with your service provider, or follow up with the funder. While rejections for duplications won’t necessarily affect the practice’s cash flow, it can create unnecessary work when identifying, fixing and resubmitting rejected claims.