Thursday, January 25, 2024

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.

Medical billing software and its role in reducing errors

Medical offices can significantly minimize or even do away with payment processing problems thanks to medical billing software.

To decrease the amount of refused claims, billing software assists office employees in correctly formatting claims and validating insurance service codes. This program may monitor your medical practice’s expenses and payments actively, improving patient satisfaction by reducing billing errors.

Medical billing software gives you a streamlined interface for controlling your office expenses, improves the patient experience, and helps you avoid mistakes. Billing software must efficiently handle patient payments while notifying you of any accounts that require particular attention. Electronic health records can be integrated with your billing solution to streamline further the procedures of tracking invoices and billing.

The effects of COVID-19 on the medical billing process

Due to the Covid-19 pandemic, the medical care sector is facing unprecedented difficulties, and medical billing management is no exception. The health and safety of patients are the top priorities in medical care as diseases spread across the country due to the Covid-19 epidemic.

The effects of Covid-19 have been felt throughout the whole medical billing and healthcare payment systems.


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.


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


Name, address, contact details, etc.


Incorrect address, policy number, etc.


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


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



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.


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.


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 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.


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.


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.


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


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.


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.


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.


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.

The role of the patient in the medical billing process

  • The patient’s part in the medical billing process, which includes knowing their insurance’s benefits and paying their expenses
  • The patient’s responsibility is to provide accurate and complete information about their current and past medical conditions.
  • Patients are in charge of informing the accountable caregiver of changes to their overall health, symptoms, or allergies.
  • If a patient is unsure of the course of therapy or their role in the plan, they are responsible for letting the doctor know.
  • Patients are responsible for adhering to the suggested treatment plan they have accepted and any advice given by nurses and other medical staff.
  • It is the patient’s responsibility to keep appointments.
  • Patients are accountable for showing respect to others.
  • The facility’s policies governing smoking, noise, and electrical equipment usage must be abided by patients.
  • If patients refuse the intended course of therapy, they are liable for the consequences.
  • The cost of the patient’s care is the patient’s responsibility.
  • Respecting other people’s property and rights is the responsibility of the patient.
  • Patients are in charge of helping to regulate the amount of noise and visitors in their rooms.

The role of insurance companies in the medical billing process

Medical billing is sped up significantly by insurance verification and authorization. Insurance eligibility must be confirmed to prevent claim denials and patient eligibility-based rejections, and permission must be obtained. Verifying the patient’s insurance information with the relevant insurance payer is part of medical insurance verification and authorization.

The insurance verification process ensures that all relevant information is verified, including payable benefits, patient information, pre-authorization number, co-payments; patient policy status; effective date; type of plan and coverage; plan exclusions; claims mailing address; and more.

Services for comprehensive insurance authorization and verification

The process for verifying and authorizing health insurance entails the following:

  • Ensuring that all patients would benefit before requesting payment to payers
  • Receiving patient schedules through FTP, Fax, or Email from the hospital or clinic
  • Confirming patient data with the insurance provider (verification of payable benefits, co-insurance, deductibles, patient policy status, effective date, type of plan and coverage details, plan exclusions, claims mailing address, referrals and pre-authorizations, lifetime maximum, and more)
  • checking the insurance status of individuals with all primary and secondary payers
  • A current patient account update
  • interacting with patients and performing administrative tasks
  • If required, request a pre-certification number from the doctor’s office
  • completing the necessary authorization forms and criterion sheets
  • Getting in touch with the insurance companies through phone, fax, or online application to get your authorization request approved
  • Contact insurance companies to discuss appeals, missing data, and other issues to guarantee correct invoicing.


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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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