Medical billing mistakes can lead to delayed payments, claim denials, customer complaints, and most important lost revenue. This is true regardless of whether a healthcare provider is associated with a private medical practice, hospital, local health department, or a local health organization. This article addresses common medical billing mistakes.
Common Medical Billing Mistakes
Not Doing Eligibility Verification
Not verifying insurance coverage is the top reason for insurance claim denials. Consider a patient that visits frequently. In this case, the staff assumes that the insurance provider or coverage plan has not changed and fails to adequately check eligibility at each occurrence. In reality, insurance information can change at any time, so verification is a critical first checkpoint in the billing workflow for every single patient visit. Following are some common denial remarks due to lack of eligibility verification:
- Coverage terminated or otherwise ineligible on date of service: There is a change in insurance status that either cancels a plan or incorporates a shift between private insurance and Medicaid.
- Services not authorized: An individual may be an active member of a health plan, but the plan will not authorize certain clinical services.
- Maximum benefits reached: In certain cases, an individual may have reached the maximum benefit for a specified time period or occurrence in his or her plan.
Insurance-related medical billing mistakes typically arise due to inefficient inpatient intake processes and procedures. Always take copies of the client’s insurance card(s), including any secondary insurance. Determine eligibility for certain CPTs. Identify plan limitations or exclusions. Assess whether any pre-authorizations are necessary. Determine if a deductible, co-pay, or coinsurance is applicable for the requested services.
Submitting Incomplete Claim
To receive payment for services rendered, providers must collect accurate and reliable information. A single empty or unchecked box on a claim can result in total claim denial. Even the most basic fields such as date of birth are sometimes left blank on a claim form, resulting in third-party payer claim denial. While one might think this is a relatively benign error, it happens all too frequently and remains a pervasive issue. The best way is to have a second set of eyes reviewing claim information on each and every paper or electronic claim filed to ensure that all required fields are completed accurately.
Lacking Specificity for Diagnostic Codes
With respect to diagnostic codes, third-party payers often deny claims for not being coded to the highest level of specificity. Trained medical billing coders understand that each diagnosis must be coded to the highest level for that code, meaning the maximum number of digits for the code being used. The most common errors include leaving off critical digits or letters (e.g., truncation), using an incorrect code from a prior version (ICD-9 instead of ICD-10), or transposing numbers or letters in listing out the ICD-10 codes for a particular visit.
Submission of an insurance claim requires an accurate depiction of the services provided to the client. The claim conveys the services provided by using different diagnostic and procedural codes. Third-party payers currently rely on the existing Current Procedural Terminology (CPT) coding system developed by the American Medical Association (AMA) and the Healthcare Common Procedure Coding System (HCPCS) developed by the Centers for Medicare and Medicaid Services (CMS).
Errors arise when providers or billing staff make mistakes entering CPT or HCPCS codes on claim forms. Errors can occur both from lack of knowledge (e.g., when a provider writes down the wrong code or code sequence) or accidentally (e.g., perhaps billing staff enters the wrong code by accident). In either case, the result can be a denial of the claim or a potential failure to pay for all services rendered.
Missing Claim Submission Deadlines
Timely filing windows can vary significantly depending on the rules adopted by different third-party payers. Some payers have two-year windows for certain types of medical claims, whereas others allow just thirty days to file. With respect to Medicare, Section 6404 of the Affordable Care Act reduced the maximum period for submission of all Medicare Fee-for-Service claims to no more than 12 months, or one calendar year, after the date of service. Many private payers have even shorter timely filing windows.
The best way that a provider can address medical billing mistakes is to proactively seek solutions that minimize mistakes at the outset. But most of the time providers are too busy in inpatient care and can’t dedicate much time for billing activities. In such scenarios outsourcing your billing and coding could be a great option. To know more about our billing and coding services, please get in touch with us!