Thursday, December 1, 2022

Potential Billing Errors And Returned Claims

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Ensuring the provider is fairly compensated for their services is the aim of the medical biller. Errors—both human and electronic—are regrettably inescapable in the pursuit of this goal. Health and money are two significant factors the medical billing process takes into account. Thus, it’s crucial to minimize these errors as much as possible. We’ll introduce you to a few typical medical billing mistakes in this article.

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But first, let’s distinguish between a denied claim and one that has been rejected.

REJECTED AND DENIED CLAIMS

Declined Claims and Denied Claims are two different types of claims.  

A claim that has been rejected has one or more flaws that were discovered before the lawsuit was processed. Due to these inaccuracies, the insurance company cannot pay the invoice as written, and the rejected claim is sent back to the biller for correction. Clerical mistakes or incorrect procedures and ICD codes may be to blame for a claim being denied. A denied claim will be returned to the biller, along with a note detailing the issue. After that, these claims are revised and resubmitted.

Scrubbing is a technique that clearinghouses utilize to prevent rejected claims. A “clean” claim is the ultimate objective for billers and clearinghouses.

Contrarily, denied claims are those the payer has processed but determined are not eligible for payment. These claims might not comply with the payer-patient agreement requirements, or they could have some serious problem that wasn’t discovered until after processing. The payer will include a justification when a claim is sent back to the biller after being denied. These claims can frequently be challenged and sent back to the payer for processing, but doing so can take a long time and be expensive.

To avoid wasting time billing for operations not covered by a patient’s insurance, getting as many claims “clean” as possible on the first try is crucial.

Easy to Happen Mistakes

After reviewing rejected and denied claims, let’s examine some common mistakes that can cause a claim to be sent back to the biller.

WRONG PATIENT INFORMATION

Name, date of birth, sex, insurance ID number, etc.

WRONG INFORMATION ABOUT THE PROVIDER

Name, address, contact details, etc.

WRONG INFORMATION ABOUT THE INSURANCE PROVIDER

Incorrect address, policy number, etc.

IMPROPER CODES

insert ambiguous Place of Service codes, ambiguous ICD, CPT, or HPCS codes; add unclear or conflicting modifiers to CPT or HCPCS codes; Enter an ICD, CPT, or HCPCS code with too few or too many digits

MISSING MEDICAL CODES

using incorrect ICD codes in place of CPT codes, or vice versa.

LEAVING OUT ALL CODES FOR DIAGNOSES OR PROCEDURES

DUPLICATE BILLING

Duplicate billing happens when a staff member at the provider’s office files a procedure claim without verifying that the service has been paid for or documented. Due to the possibility that a patient had two identical x-rays on the same day, duplicate billing can be highly frustrating for both billers and payers, effectively doubling the amount given to the payer.

Similar to medical coding, we constantly aim for the highest accuracy in our codes and must give the most thorough description of the medical procedure (s).

You’ll have many more clean claims if you can reduce the frequency of these easy billing mistakes.

MORE ERRORS IN MEDICAL BILLING 

Those, as mentioned earlier, are a few of the most typical mistakes a medical biller encounters. They should carefully scrutinize these mistakes because they directly impact the status of a claim.

But as a medical biller, there are other mistakes you should be aware of. Although some of them are regretfully beyond the biller’s control, the biller should avoid errors.

UNDER CODING

When a practitioner purposefully omits a procedure code from a superbill or regulations for a less painful or involved procedure than the patient received, under-coding has occurred.

Under-coding could be done to save the patient money or evade audits for specific operations. This procedure is against the law and constitutes fraud.

UPCODING

Upcoding is a dishonest practice similar to under-coding, in which the physician knowingly misrepresents the job they did on a patient. Upcoding is entering codes for operations or services the patient did not receive or more complex ones than the practitioner carried out. Upcoding is frequently done to get paid more by a payer. This fraudulent activity needs to be detected and addressed right once, just like under coding.

DEFICIENT DOCUMENTATION

Poor documentation, while not a fraudulent activity like upcoding or under-coding, can still have a detrimental impact on the claims process.

It might be challenging to submit an accurate or comprehensive claim if a provider has offered inaccurate, unreadable, or incomplete documentation of a procedure or patient visit. When there is poor documentation, the biller should contact the provider and request more details.

DENIED CLAIM WITHOUT EOB

The Explanation of Benefits (EOB) may occasionally not be attached by the payer to a denied claim. In situations like this, it can be challenging to identify the error on a refused claim, slows down the appeals process, which is already cumbersome.

FIXING ERRORS BEFORE THEM OCCURRING

Being proactive is crucial when it comes to medical bills. Here are a few steps you may take to prevent medical billing mistakes.

  • REMAIN CURRENT

Billers must keep up with the latest billing and code developments. As new codes are implemented, and outdated ones are phased out, coding will change. It’s crucial to review updated medical coding guidelines routinely. Know how new regulations affect billing by studying them.

  • BE CAREFUL

When making a claim, you should always double-check your work. Check each claim you write before submitting it since little administrative mistakes like missing figures or misspelled names might mean the difference between an authorized and a rejected claim.

  • COMMUNICATE 

Effective coordination within the provider’s office is key to lowering medical billing errors. Make sure you speak frequently and effectively with other office staff, including the doctor, and don’t be afraid to inquire about potential claim problems.

  • BEAR WITH US

After submitting a claim to a payer, you can contact the agent handling it. If they find any errors, they might be able to let you know so you can start working on a new, error-free claim.

 

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Dennis
Dennis
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. I am certified by the American Academy of Professional Coders (AAPC) as a Certified Professional Coder (CPC) and by the Practice Management Institute (PMI) as a Certified Medical Office Manager (CMOM). As an office manager/biller/coder, I was a member of the Michigan Medical Group Managers, Michigan Medical Billers Association. I also served as a committee member of the Michigan Osteopathic Association of Practice Managers Education Committee.

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