Navigating Diagnosis Denials

RCM Operations Director: Brianna Crowley

A growing concern in the healthcare system is the increased amount of diagnosis denials. Insurance companies are refusing to cover certain diagnosis or treatments. Diagnosis denials can delay, decrease, or cause a loss in the revenue you are entitled for treating patients.  It is important for urgent care centers to optimize their processes to reduce denials.

Insurance companies may have policy limitations that can result in a denial if a diagnosis is billed that is not included in the patients’ covered benefits. In addition, some insurance plans require a pre-authorization for certain diagnosis or treatments. It is important for front desk staff to obtain a pre-authorization, when necessary, to prevent a loss in revenue.

Thorough and accurate documentation is critical for proper coding and reimbursement. Incorrect or incomplete diagnosis codes can lead to denials. There are several reasons why a claim might deny for invalid diagnosis, including: the diagnosis and age are in conflict, the diagnosis and sex are in conflict, or the diagnosis is unspecified. Providers should refrain from choosing an “unspecified” diagnosis whenever possible. Selecting the most specified diagnosis is beneficial to ensure a better chance of reimbursement.