Top Reasons Why Your Medical Claims Are Being Denied

Colburn Law

Posted in Blog,Medical Malpractice,Personal Injury on February 12, 2023

Navigating the world of healthcare can be a challenging experience for many patients, particularly when it comes to medical claims. Whether you’re dealing with a chronic condition or a sudden illness, the last thing you want is to be faced with a denied claim. 

Unfortunately, medical claim denials are a common occurrence and can be frustrating and costly. When an insurance company denies a medical claim, the patient can experience higher healthcare costs, delayed treatment, and even debt. The reasons for denials can vary widely, but some issues are more common than others.

#1: Inaccurate Information

One of the most common reasons for medical claim denials is inaccurate information. This may include incorrect patient information, incorrect billing codes, or inaccurate dates of service. 

Incorrect data on claims forms can lead to confusion and errors in the billing process, causing the insurance company to deny the claim. To avoid this issue, patients and healthcare providers should ensure that all information provided on medical claims is accurate and up to date. 

#2: Lack of Medical Necessity

An insurance company may deny medical claims if they believe that the treatment or service provided was not medically necessary. This can be especially problematic if the treatment or service is expensive or considered experimental. 

Providers need to be sure that all potential treatments are supported by medical evidence and deemed medically necessary. They need to carefully document the patient’s medical history and condition to justify the services they want to administer.

#3: Pre-Existing Conditions

If an insurance company believes that a patient’s condition was present before seeking medical care, it may deny the claim. This is a common reason for medical claim denials when a patient has a history of medical issues or is receiving treatment for a chronic condition.

To avoid this issue, patients and providers should carefully document the patient’s medical history and provide evidence to support that the current condition is not a pre-existing condition. This may involve obtaining medical records or having the patient undergo additional testing.

#4: Incorrect Coding

Insurance companies and healthcare providers assign billing codes to specific services, which helps the company determine whether a service or treatment is covered. If an incorrect billing code appears in the paperwork, the company may flag a covered service as one that it will not pay for. 

Coding errors can be costly, resulting in denied claims and higher healthcare costs. Healthcare providers need to double-check that all billing codes are accurate and up to date. 

#5: Timeliness

Insurance companies have strict deadlines for submitting claims. If a claim is not submitted on time, it may be denied. Providers should ensure that these claims are sent before the appropriate deadline and ensure that all required documentation is included with the claim.

Contact a Personal Injury Lawyer Today

Dealing with a denied medical claim can be frustrating. A denial can leave you in a vulnerable financial position, especially while recovering from a recent injury. Depending on your circumstances, however, you may have another avenue to compensation: filing a personal injury lawsuit.

If someone else’s negligence caused your injuries, you could file a lawsuit against him or her and recover compensation for your medical care, lost wages, and more. As soon as possible after your accident, contact a Washington personal injury attorney to discuss your legal options.