Challenges in Securing Reimbursements
For any practice owner, submitting error-free claims and securing accurate insurance reimbursements is the most important and at the same time most challenging task. Things even get worse due to sloppy billing and coding mistakes practices. As per CMS (Centers for Medicare & Medicaid Services), Medicare, claims worth $6.25 billion in fee-for-service, were improper under its coverage.
Fortunately, there are steps doctors and practice administrators can take to ensure they receive all they are owed in a timely fashion. But it requires forethought, training, and commitment from everyone in the practice. Most practice owners doing medical coding all by themselves justify it by saying they didn’t go to medical school to become medical coders or billers.
Nevertheless, medical coding is the inescapable part of revenue cycle management, and doing it poorly can have severe financial consequences, either from frequent claims denials or overbilling that the practice must then repay. In this blog, we shared 7 billing and coding mistakes to avoid for any practice owner in the Year 2022.
7 Billing and Coding Mistakes to Avoid in the Year 2022
1. Expenses not covered by a patient’s insurance:
This is the most common coding mistake done by practice owners. Practices must conduct eligibility and benefits verification for every patient visit. Eligibility and benefits verification helps to find out insurance coverage for the planned procedure. It helps in finding a number of covered visits, unpaid deductibles, and co-payments so that you can share exact cost estimation with patients with full price transparency.
2. Expired insurance coverage:
With a benefits report you can confidently communicate with patients for cost estimation. In the case of covered medical services, a patient just has to pay the co-payment amount at the time of the visit. It’s really difficult to recover the patient’s responsibility for non-covered services. And as the patient leaves the office, with the passing days, the possibility of collecting patient payments fades away.
3. Lack of coordination of patient benefits:
COB or coordination of benefits refers to the process of determining a health insurance company’s status as a primary or secondary payer to provide medical claim benefits for a patient having multiple health insurance policies. Most practices, don’t ask for secondary insurance information. With COB it is much easier to determine the responsibilities of the primary payer and settle on the contribution of the secondary payer while processing the medical claims.
4. Lack of required precertification/authorization for an expense:
Any claim that got denied due to prior/pre-authorization/certification is considered a hard denial i.e., an insurance carrier may not reverse their decision. With more and more patients opting for High Deductible Health Plans (HDHP), prior authorization request has increased to a considerable amount. Based on your medical specialty, you must have a list of procedure codes that might require prior authorization. As mentioned earlier, when a claim got denied due to the absence of prior authorization, it is really difficult to reverse
5. No Specific Clinical Notes:
Providers can minimize claim denials by making sure their notes are concise, detailed, and specific. Diagnosis lacking specificity is one of the biggest reasons for denials. Putting in the clinical details such as the problem’s severity and whether it’s chronic or acute will get you to the most specific diagnosis code and get your claim paid faster.
6. Non-Documenting Time-Based Services:
When time is used for reporting E/M services codes, documenting is a must. Most providers use a few bunches of procedure codes again and again for all the procedures, this may lead to a coding audit.
7. Other Mistakes:
Apart from above mentioned other mistakes include, the note is not signed; the billing provider’s and service provider’s names don’t match; the note doesn’t support the CPT codes reported for it; CPT codes are inconsistent with the place of service; the patient has reached the benefit maximum for the time period; claims are duplicated; procedure/modification combinations are incompatible; referral(s) are not listed on the claim.
The best way for any practice owner to prepare, especially individual and small group ones, is to stay updated on billing guidelines and reimbursement policies. You must always plan to be audited at some point, and don’t assume everything’s OK as long as you’re getting paid. As a practice owner, if you don’t have time for perfecting revenue cycle management activities, we can help.
Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle solutions. Our billing services will help to receive accurate insurance reimbursements for private and government payers.To know more about our medical specialty-wise billing and coding services, contact us at info@medicalbillersandcoders.com/ 888-357-3226
FAQs
1. What are common billing and coding mistakes that lead to denied claims?
Common mistakes include failing to verify insurance coverage, not obtaining prior authorization, and submitting vague or incomplete clinical notes, all of which can lead to claim denials.
2. Why is eligibility and benefits verification important?
Verifying insurance coverage before a patient visit helps ensure the procedure is covered, preventing unexpected costs for both patients and providers, and improves billing accuracy.
3. What is Coordination of Benefits (COB) and why is it necessary?
COB determines which insurance plan is the primary or secondary payer when a patient has multiple policies, helping to ensure accurate payment allocation from both insurers.
4. What happens if a claim is denied due to lack of prior authorization?
Claims denied for lack of prior authorization are usually considered “hard denials” and are difficult to reverse, making it crucial to ensure all necessary authorizations are obtained beforehand.
5. How can clinical notes affect claim denials?
Detailed, specific clinical notes are essential to avoid denials. Inadequate or vague documentation can lead to coding errors and delays in reimbursement.
