7 Reasons Insurance Claims Get Rejected And How Superbills Help

Claim denials are as frequent as day and night. Nearly 20% of claims are denied by insurance companies, with studies indicating an even higher rate for certain types of claims. CNBC reported that in 2023, 73 million (19%) of 392 million in-network claims were rejected in the country. So many people have been there before, and if you’re trying not to suffer the same fate, this piece is for you. We’ll discuss the top seven reasons for this recurrence and how to avoid them. We’ll also highlight the relevance of superbills in steering clear of denials. 

Reason 1: Incorrect or Incomplete Information

This stands as one of the most basic reasons that claims get rejected, and it’s surprising to see how many people make such mistakes. Providing incorrect details in your submission is the easiest way to delay your claim or have your application rejected. Firstly, it presents you as someone who is unserious and not attentive to details. At the same time, it puts some doubts in the mind of the insurance company, signaling possible foul play. How can you avoid this? Double-check all forms and documents before final submission and contact your insurance companies to put you through to an agent in cases of confusion. 

Reason 2: Late Claim Submission 

Many people are also guilty of submitting their claims after the policy has expired. If your policy is inactive, there is no way you’re getting a response. Understandably, humans like to take action with a positive mindset, hoping that there could be an exception in their favor. Such a mindset is invalid when it comes to insurance claims. These companies strictly adhere to their policies, and late claims are never viable. Always set a reminder for your policy renewal dates, and keep in touch with your insurer to get prompt notices. 

Reason 3: Invalid or Incorrect Coding of the Bill

Insurance companies rely on accurate codes to assess what services were performed and why, so it’s essential to have the correct information regarding this. It’s particularly dire for health insurance claims because there are millions of others filing a claim, and a single digit can change the entire direction of your claim. Double-check all codes with your healthcare provider before submitting. 

Reason 4: Duplicate Claim Filed 

Duplicate claim submissions are not uncommon, and submitting one can trigger an automatic rejection. If your claim is mistakenly filed more than once, then you can expect to meet the same fate.  Insurers are programmed to detect duplicates to avoid overpaying, so they automatically reject any claim that appears to have already been processed. One way to prevent this is to track submitted claims and their status before resubmitting. Another option is to use superbill insurance claims, as they help reduce confusion about what has already been billed. 

Reason 5: Lack Of Proper Documentation

Insurers often require specific documents like medical records, police reports, photographs, and other things that can help them prove that your claims are solid. Failing to meet such requirements puts you at risk of being rejected. Some details that are mostly non-negotiable are 

• Detailed progress or visit notes
• Procedure codes
• Date and duration of service
• Credentials and signatures 
• Supporting documents like labs, imaging, referrals, and others 

Reason 6: Non-Covered Charge 

A non-covered charge denial happens when a patient or provider submits a claim for a service that the insurance plan doesn’t cover, either wholly or at all. This means the insurer will refuse to pay, regardless of how well the claim is documented or how it is submitted. A non-covered charge is a service or procedure that is not included in the individual’s plan benefits or is considered elective or cosmetic, among many others. It’s important to know what is valid or not before submitting a claim. 

Reason 7: Lack of Pre-authorisation

Another common cause that people sometimes overlook is a lack of preauthorization. It happens often, especially for services that are expensive, specialized, or elective. Pre-authorization, which is also called prior authorization or pre-certification, means the insurance company must approve a service before it’s performed—otherwise, they won’t pay for it.

Understanding Superbills and How They Help

Superbills can be your best bet when it comes to medical billing because it is prepared and issued by the healthcare provider to avoid any errors. Superbills are charge slips or detailed invoices that give a comprehensive breakdown of the services rendered to the patient, including costs, codes, and other details that your insurer might need to see. What makes Superbills better is how they’re carefully done by professionals. Once this document is concluded, it’s sent to the patient and insurance during the medical billing process for final confirmation. This route can significantly reduce denials and help you receive faster reimbursements. 

Mastering the Insurance Game

If you follow the tips above, you’ve already eliminated 99% of the chances of having your claim rejected. The key is to follow instructions to the letter and ask questions of your provider at any point you feel confused. The superbill is also a great option; you can trust the healthcare provider to do a thorough job and give you better chances of getting your claim approved.