How does the auditor deny claims?

They are the scrutinizers. The claim sniffers. They are the auditors. Have you ever thought of why your claims are denied or paid? Is there a really smart computer or a human face behind that hits to go or the no-go button? It’s both. When you submit claims, they go through some really intelligent computer programs. These programs process each claim and flag irregularities. These red flags are then extensively analyzed by claim auditors.

Traces an auditor looks for.
Auditors compare the submitted claims against quality benchmarks that insurances set. These include claims coding analysis, modifier usage analysis, insurance and regulatory compliance, visit and health record documentation. Alternatively, they look for trends. For example, a frequent trend is duplicate claims submission.

Consequences of audit.
If any discrepancies are detected, auditors deny the claim. In cases where payments have been made, recoupment follows the audit.

Recommendations by auditors.
1. Follow ethical coding guidelines while submitting the claims.
2. Take into account the compliance guidelines laid down by the insurances.
3. Avoid malpractices for higher reimbursements.

As an auditor, before hitting the pay button I think of denial. I look into all aspects – coding, billing, eligibility, benefits and most of the claims have some or the other loophole which helps me deny the claim. I have always been taught – its your check book & you are making the payment on claim.
– Anonymous auditor (name withheld)