Claim denials in healthcare are a significant issue for both patients and providers. Denials lead to major financial loss for healthcare providers and patients are at risk of receiving substandard medical care. Statistics show that in the U.S., approximately 5-10% of all healthcare claims are denied. This can vary depending on the insurer, state, or healthcare provider.

The best way to avoid claim denials is to follow a proactive approach while filing claims, understand the most common reasons that cause the denials, and avoid errors and inaccuracies for a successful claim submission.

Common Reasons for Claim Denials

While there are numerous reasons for claim denials, administrative and coding errors are among the most common causes, often accounting for a significant percentage of rejections. According to a study by Navicure (now part of Waystar), nearly 60% of all claim denials are due to coding errors or missing codes.

Administrative Errors for Claim Denial

• Missing or Inaccurate Patient Information
• Eligibility Errors
• Duplicate Claims
• Delayed Claim Submission
• Billing errors

Coding Errors for Claim Denial

• Missing or Incorrect Modifiers
• Duplicate Coding
• Incorrect Place and Date of Service
• Invalid Code Pairing
• Lack of Medical Necessity

Preventive Measures to Avoid Claim Denials

Taking proactive steps to reduce claim denials by focusing on better documentation and improving coding accuracy is imperative. AI integration can further streamline these processes, reducing the risk of human errors and enhancing efficiency.

1. Ensure Accurate Documentation

Healthcare providers must document patient encounters in detail, including symptoms, treatments, and diagnoses as incomplete or vague documentation results in claim denial. AI-powered tools like Lynk provide effective documentation by leveraging AI-enhanced IDP (Intelligent Document Processing). Lynk AI IDP can classify and extract relevant information from several documents (structured and unstructured) quickly and accurately. It can transcribe doctor-patient interactions and flag inconsistencies or incomplete entries, prompting healthcare professionals to correct them before submitting claims.

2.  Submit Claims with Correct Codes and Modifiers

Lynk AI uses NLP to ensure coding accuracy by identifying outdated or mismatched codes with the services provided. It also analyzes patient data, including clinical notes and medical records, to recommend the most accurate codes and cross-check them to comply with payer requirements, reducing the likelihood of claim rejection. Additionally, Lynk AI can suggest the correct modifiers based on the patient’s diagnosis and the medical care received.

3.  Verify Patient Eligibility

Lynk uses AI-enhanced OCR to scan insurance copies, patient records, medical files, previous claim records, and current claim forms to verify and validate insurance coverage and eligibility in real time. AI-powered tools like Lynk use Machine Learning Algorithms to extract required data such as patient eligibility and benefits, from available documents before filing the claim, thus reducing claim denials due to incorrect information.

4.  Monitor Denial Trends

Lynk’s predictive analysis can process large amounts of claims data to identify trends, such as specific codes, providers, and procedures that are frequently denied.  By regularly monitoring denial trends, the claim submission process can be refined and claim denials can be prevented even before submitting the claim.

5.  Prioritize Claim Submission

Lynk AI can segment claims based on risk level, and help administrative teams to prioritize the claims that are more likely to be rejected. This ensures that the most critical claims are addressed and corrected before submission. Claim segmentation also helps staff prioritize and submit claims that are most likely to be approved sooner.

AI-Driven Claim Denial Prevention

By leveraging AI for tasks such as claim validation, predictive analytics, real-time eligibility checks, and accurate coding, healthcare providers can reduce errors, minimize delays, and improve reimbursement rates. Lynk AI can not only help prevent claims denials but also assist in building a robust healthcare denial management system.

Visit our website to learn more about how Lynk AI can help you prevent claim denials and improve RCM and patient care.

Contact us @JediTeck