Tuesday, October 19, 2021

Medical Billing Problems & Returned Claims

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Medical Billing Problems & Solutions

The primary responsibility of the medical biller is to make sure that the provider is correctly making the repayment for their services. Unfortunately, when working to achieve this goal, employees working in the healthcare field or anyone can usually make problems or errors.

Medical Billing

Since the medical billing process dealing with the two most important parts (means, health, and money), it’s crucial to decrease as many of these errors as possible. In this article, we’ll talk about some usual errors identified in the medical billing process.

Firstly, let’s see the difference between a rejected and denied claim before visiting the medical billing errors.

Denied and rejected claims

A rejected claim and denied claim are not the same. A rejected claim can have one or many errors before processing the claim. These errors prevent the insurance agency from paying the bill as its creation. A denied claim might result from an administrative error, or it might come down to the mismatched procedure and ICD codes. A rejected claim will return to the biller with an explanation of the error. These claims are then reviewed and submitted again.

Clearinghouses are working on a process called “scrubbing” to avoid rejected claims.

Denied claims are claims that the payer has worked and is considered unpayable. These claims may break the terms of the payer-patient contract or have some critical mistakes recognized after the processing. Payers will explain why it is a denied claim and send the claim back to the biller. These claims can often be requested and sent back to the payer for working, but this process can be tedious and, therefore, expensive. For that reason, it’s essential to create many clean claims from the first time.

Simple medical billing errors

There can be some of the fundamental errors that can be a reason for return back claims to the medical biller.

  •   Wrong patient details

Sex, name, DOB, insurance ID number of the patient.

  •   Incorrect provider details – Address, name, contact details of the provider.
  •   Incorrect insurance provider details – Wrong policy number, address.
  •   Wrong codes

Entering mismatch ICD, CPT, or HPCS codes, Place of Service codes, attaching conflicting or wrong modifiers to HCPCS or CPT codes, or entering too few or too many digits to an ICD, CPT, or HCPCS codes.

  •   Incorrect medical codes

Enter mismatch ICD codes with CPT codes, or vice versa.

  •   Duplicate billing

Duplicate billing happens when a provider submits a claim for a procedure without checking whether that service has been informed. The same billing can create a massive mess for billers and payers because it may look like that a patient received two similar x-rays on one day, which would grow the amount sent to the payer.

Mostly, billing mistakes can happen during manual billing and spreadsheet management.

We can automatically create a bill and identify duplicates if someone starts an additional invoice for the same services and treatments by automating this process.

More medical billing errors

The above are some of the most common mistakes a medical biller comes across. These errors directly influence the status of a claim, which makes them very critical to check.

There are more errors to check out as a medical biller. Unfortunately, medical billers haven’t to do anything with some of these errors, but it’s essential to check.

  •   under coding

Under coding happens when a provider purposely leaves out a procedure code from a superbill or regulations for a less painful or huge procedure than the patient received. Under coding may be done to give away audits for exact operations or save money for the patient. This process is not legal and counts as a type of cheating.

  •   Upcoding

Like under coding, this is a false process hence the provider purposely distorts the work they performed on a patient. In upcoding, a company enters codes for services a patient did not have or more in-depth procedures than the provider never performed. Upcoding is commonly used to get more money from a payer. Upcoding, like under coding, is dishonest work and should be noted and reported immediately.

Upcoding errors can happen if the billing department workers make a mistake when entering codes or if the worker hasn’t any clear idea about the details provided by the doctor or physician.

  •   poor documents

While not dishonest work like up-coding or under-coding, poor documents can also negatively affect the claim. If a provider has granted an improper, unlawful, or corrupted record of a procedure or patient visit, creating a correct and complete claim is challenging. In cases of poor documents, the biller has to contact the provider and ask for more details.

  •   no EOB on a denied claim

In some cases, the payer might miss attaching the Explanation of Benefits (EOB) to a denied claim. So, it’s hard to remark the mistake on a denied claim, which lowers the claims process.

  •   Not Enough Data

Failing to give details to payers to support claims results in denials or delays. For example, problems can happen if billing department employees don’t link a diagnosis code to the Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code or add a fourth or fifth digit diagnosis code.

While employee makes some of these mistakes, it can also happen if doctors don’t give correct diagnosis details.

  •   Telemedicine Coding Errors

Healthcare technology makes providing quality care to patients in multiple locations much more manageable, complicating the billing process.

Unfortunately, mistaken use of modifiers for telemedicine services results in payment stoppages. For example, the GT modifier connects to real-time telehealth services rendered by audio or video systems. In opposition, the GQ modifier includes services rendered throughout asynchronous telecommunications systems, like an emailed X-ray.

  •   Missing or Incorrect Information

Errors are a typical cause of claim denials and can easily override by carefully checking all fields before submitting a claim. For example, patients’ wrong names, addresses, BOD, insurance details, sex, treatment dates, and onset can all cause problems.

Although it may rarely happen, sometimes information is mistakenly entered into the wrong patient’s record. For example, a claim denial will follow if billing workers only enter the details given and don’t observe the odds of treatments and diagnoses. Unfortunately, in busy billing departments, they miss the patient details easily.

Therefore, it’s best to find out failures before going through a time-consuming denial and resubmission process. 

There are two ways to handle this problem and prevent it from happening. The first is to check twice all entries you make to assure that it’s correct. The second is to take software that auto-fills the patient bill based on their confirmed data. For example, suppose you have patients enter their data and secure it with you before their first initial evaluation appointment. In that case, there’ll be virtually no chance of this kind of mistake delaying a payment.

  •   Improper Coding

Improper coding of medical claims is one of the most popular and time-consuming errors made by physical treatment practices. Several reasons for happening improper coding is:

  1. Use of outdated coding books
  2. Unbundling of charges should handle under the same procedure code
  3. Upbilling and underbilling
  4. Mismatched codes
  5. Missing codes
  6. Billing CPT codes that are not in the insurance contract

While up billing and underbilling may be fraudulent, they can also occur by accident. The option is to take a medical practice management solution that involves updated coding automation to follow current coding requirements.  Using software that can only list codes specific to each medical insurance carrier can quickly reduce billing time and leave no room for errors.  When your staff can look up diagnosis codes and procedure codes rapidly, the chances of making a mistake can reduce significantly.

  •   Service Not Covered

Patient insurance coverage can change for many reasons, like a change in employment. There might also be restrictions on how many physical treatment visits or treatments are covered, and when a patient maxes out on their coverage, they should pay out of pocket. Improperly billing an insurance company can lead to costly delays and make collecting from the patient or their new carrier more difficult.

The solution is to check the patient’s coverage at each visit. You’ll need to ask the patient to ascertain their insurance while checking to ensure that their benefits have not maxed out.

  •   Missing recommendation or authorization

Some medical plans need patients to recommend a primary care physician or authorization from patient services before physical therapy. If the requestor’s approval is missing, it will be a denied claim.

Here again, you’ll need to double-check with the patient and confirm that your staff is familiar with carrier limitations and requirements. Furthermore, if the referral is missing, you can work with the patient to get it before you submit the claim.

How to Correct Medical Billing Errors

It’s always essential to work hard when you’re in the medical billing field. Here are a few things you can do to identify medical billing errors before they happen.

  •   stay updated

Billers need to stay updated on billing and coding trends. Coding significantly will change as new codes are coming and older ones phased out. Therefore, it’s vital to check constantly on new terms in medical coding. In addition, the coding manual must appropriately update every year.

  •   be diligent

It would be best if you always double-check your work when you’re creating a claim. Simple clerical errors like missing digits or misspelled names can differ between an approved and a rejected claim, so go over each claim you make before sending it off.

After the claim rejection, taking a few minutes to verify the information could save several hours or correct it.

  •   communicate

Part of decreasing medical billing errors comes down to adjusting efficiently in the provider’s office. Ensure you communicate frequently and efficiently with other employees in the provider’s office, including the doctor, and don’t hesitate to ask about possible errors on the claim.

  •   follow-through

After sending a claim to a payer, you can follow up with a representative working on that claim.  

It is an excellent practice to always try for the highest accuracy in the codes like medical coding. If you can lower down on these external errors in medical billing, you’ll have much higher clean claims.

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Dennis L. Hernandez
I am a medical biller, a blogger and have 20 years of experience in medical billing, medical billing management, and medical assistant. My background includes positions as a clinical medical assistant, medical records technician, medical office manager, biller, and coder.

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