Is it honest mistakes or mistakes by purpose? We use to wander every month after looking at the process dashboard. Even though we keep the tools and checkpoints in place, it feels like slipping through the cracks. In the event where you can recognize a common mistake and the one Clinical Specialist make, we can make an attempt to dodge them.
Patients most of the time are not aware of their benefits, coverage, and coverage during emergency situations. A mistake can happen in many places in the patient’s account resulting in an unclean claim, or a wrong balance on a statement.
There is a lot of misplaced views held by the general public. Excessive fear of reprisal causes most junior doctors to commit minor mistakes they otherwise wouldn’t make. In the below articles we discuss some of the common mistakes committed in the Claims that you can avoid in the future.
Sending Duplicate claims
While sending the claim to insurance, billing professionals may click the submit button twice, then one of the claims will become duplicate.
Another main reason for this denial is not submitting the ‘corrected claim’ properly. We need to mention the corrected claim in the CMS 1500 form every time according to the insurance requirement.
To further complicate things, Insurance has a specific process for how they accept claims. To receive payment your doctor must follow that process. There are thousands of checkpoints systems used to determine whether to accept or reject a claim.
Incorrect Patient Demographics
Incorrect Patient information may cause denial, the checkpoint is put in place via clearinghouse while submitting, but the ‘jr’ and ‘Middle name’ can be missed out and it is enough to do the damage for the claim.
It can even be complicated if the patient changed his insurance plan and we submitted it to a different department. This can cause confusion and the billing side and end up in an appeal. Identification of the right population segments based on demographics data is important for reimbursement.
Wrong Medical Documentation
When you are billing the claim that as a complication it is important for the insurance to verify the medical documents. This can be more applicable while working on Durable Medical Equipment(DME). Even though we obtain the proper authorization for the claim, some insurance company also demands to submit the medical records.
If the medical records are stuck with the Physician and if there is no proper communication between the provider and the medical billing company. It may be ageing in the bucket for a long period of time. This can be avoided by using EHR or other electronic medical record software.
The constant change in Regulations and payer requirements
The affordable care act changed the US healthcare system and made healthcare affordable for more patients. So insurance companies found different methods to confuse the patients. One of the biggest problems with insurance companies is changing rules and regulations. This causes confusion among providers. With the added regulations come added forms, pre-qualifications, etc etc etc.
One payer may require a “modifier” code and another payer will send the bill back and request that the modifier be removed due to some internal code change or government regulation that affects them
Misinterpretation between technologies
Most of the small medical practices haven’t fully transitioned to digital. EMR or Electronic Medical records may greatly be benefited in the future. But currently, the cost is high for maintaining the medical records for the patients.
And it would be difficult for the billing company ]to work towards obtaining the medical records. And this causes confusion and the bill may be submitted without the required clinical and causes the denials.
Patient Policy Expired
The Clearinghouse checks for the patient’s eligibility before submitting the claim to the insurance. But sometimes, patients may change the plan internally and we needed to submit it to a different Payer ID in the EDI(Electronic Data Interchange).
These kinds of scenarios occur especially when the patient is having Managed care plans, where the plan changes monthly, and once the billing agent calls the insurance company they will tell them to submit to the different insurance.
Incorrect Manual and Automated coding
ICD-10 was implemented in the US from Oct 2015. Inexperienced coders make lots of mistakes in determining the Diagnosis(Dx) and Procedural code. It is also advisable for doctors to verify the Local Coverage Determination(LCD) and Insurance guidelines for the procedures that are most billed.
We need to check whether Bundling/Unbundling a procedure code is coded per the insurance guidelines. Sometimes even the right combination of codes may deny stating Bundled per the insurance guidelines. An experienced Medical Billing Coder will recognize it initially and stop it from occurring.
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