The growing incidence of delays, denials, audits, and resubmission of physicians’ medical bill claims is reason enough to have a relook at the way physicians’ services are billed and coded. In a medical insurance environment, characterized by stringent billing and coding compliance, inherent billing and coding errors are easy to catch. Further, lack of knowledge or negligence can be no excuse as payers go by the set rules that govern medical bill reimbursements.
As physicians try to figure out lacunae in their billing and coding practice, researchers have traced the reasons to lack of knowledge, negligence, outdated coding knowledge (physicians still trust what they learned 10 years ago!), inadequate in-house billing and coding competence, and, sometimes, incompetent outsourced billing and coding solutions. Delving further, they have even identified patterns of usual billing blunders.
- Failure to document services billed: A common error, physicians often forget to bill for incidental services while addressing the main medical disorder, which can substantially reduce the final realization. Therefore, physicians should realize the importance of billing for medically necessary, though incidental, services also.
- Failure to provide signatures: There have been instances of medical claims being returned unpaid and to-be-resubmitted again on account of omission of signatures by the physicians billing for their medical services. As physicians’ signatures only can validate the medical services that are billed for reimbursement, it is important that physicians, while submitting claims, do not forget to sign in wherever required so as to avoid being embarrassed with notices for resubmission.
- Consistent assignment to the same level of service: It is inviting suspicion as your payers might term ‘consistent assignment to the same level of service’ as duplication, and return the subsequent claims as invalid. Further, they may ask for explanation on the efficacy of repeating the same service again. To avoid, such undesirable scenario, a higher order coding is advised for subsequent services.
- Billing as a consult rather than an office visit: Although, at the outset, they might seem similar, consulting fee is deemed higher than regular office visit. Misrepresenting your manner of service will have a direct bearing on the outcome of reimbursement, and upon being found out by the payers’ audit checks, you may be called upon to furnish a suitable explanation. Therefore, code for the correct context to avoid being exposed during audits.
- Use of invalid codes (for example, codes taken from an outdated resource): The prime reason behind most billing blunders is the physicians’ perception that billing and coding standards are permanent; whereas there have been as many reforms as one can think of in billing and coding. Therefore, they need to keep themselves abreast of frequent changes in coding.
- Unbundling of procedure codes: Physicians, albeit unknowingly, or their billers, tend to fragment their procedure into parts, and assign codes accordingly. Whereas insurance companies, which feel such fragmentation tends to disproportionately increase claims, are known to have sent notices requesting physicians to not to unbundle their services.
- Misinterpreted abbreviations: Abbreviations, meant for reducing description, need to be used suitably to avoid a billing lapse.
- Failure to list chief complaint: Physicians, sometimes, looking for incidental charges may forget to state the chief medical complaint itself. Such mistake can render your claim as ‘insufficiently substantiated,’ and returned with audit remarks.
- Billing as a separate professional fee for those services included in a global fee: Physicians – not knowing the extent of coverage that their patients insurance schemes allow – sometimes, tend to club additional professional services while billing for certain cases that carry global-fee tag. As the insurance companies are obliged to reimburse only the global fees, physicians might not get the reimbursement for what they claim to be additional services.
- Use of an inappropriate modifier or no modifier for accurate payment of a claim: Modifiers – which play an important role in suitably modifying codes for incidental medical services – need to be used with discretion. Rampant and indiscriminate use of modifiers can be termed as ‘unacceptable practice’ and be eligible for ‘audit notes’ from your insurance carriers.
Given the pattern of billing blunders, and their consequences on claims realizations, individual physicians, clinics, hospitals, and multispecialty groups should look at devising a preventive program that can mitigate the recurrence of billing blunders in the larger interest of their sustainable practice and growth. Consequently, the preventive program entails
- Educating themselves and their staff on proper coding
- Continuous upgrades in terms of latest updates in coding
- Continuously assessing the coding procedures to identify the most common errors and reduce them
Whereas these positive measures can be practiced internally, yet, physicians – who tend to be wary of exhaustive billing management practices – can fall back on proven outsourced solutions to meaningfully streamline their billing processes for optimized reimbursements. Medicalbillersandcoders.com, who a have long-standing reputation of being the largest medical billing consortium with a substantial presence across all states of the US, should be of immense help in devising a comprehensive program that can effectively quell billing blunders.