Clean reimbursement claims are the bread and butter of the medical billing industry. They pass the scrubbing process at clearinghouses quickly and generate revenues faster. Billers can take a variety of precautions to avoid denied claims and in this telling article, Nitin Chhoda reveals the most common billing mistakes.
The first rule of medical billing is never assume anything. If a medical insurance biller (MIB) has any doubt due to a practitioner’s illegible scrawls, the type of treatment received or procedure performed, it’s imperative to contact the clinician for clarification.
Mistakes and oversights in coding represent the number one reason that reimbursement claims are denied. Electronic medical record (EMR) technology can identify potential claim problems and notify the user. Insurance carriers are constantly seeking ways to avoid paying reimbursement claims and examine coding closely for the following items:
- Mismatched coding that creates inconsistencies in the claims. A good example is gender specific ailments.
- Truncated coding doesn’t address all three levels of the practitioner’s diagnosis is suspect.
- Up and down coding is a red flag for carriers. Trying to obtain higher reimbursement claims or coding at a lower level in an effort to avoid denials can result in penalties, or the carrier may decide not to do business with the clinician.
Clean claims provide the appropriate documentation for every item, from the patient’s identity to the treatment provided. MIBs must ensure that reimbursement claims contain complete and accurate information on all facets of the patient’s visit.
When claims are returned with a request for supporting data, insurance carriers can become suspicious and suspect the medical provider or the MIB of altering or recreating documents to support a claim.
Unbundling is the act of billing separately for elements that should have been claimed as a whole. Insurance carriers allow for unbundling under very specific circumstances, but MIBs should utilize caution when doing so. Coding is designed to cover an entire treatment or procedure and will single out a claim for closer inspection.
Complying with Carriers
There’s no standard procedure when dealing with insurance carriers. Each company establishes its own rules for reimbursement claims submissions. MIBs who don’t adhere to the carrier’s specifications will be deemed non-compliant and the reimbursement claims will be denied. That can also encompass failure to obtain a pre-approval prior to the patient’s treatment.
Correct coding and detailed documentation won’t avoid a denial if the reimbursement claims contain omissions, data entered in the wrong location or typographical errors.
Even simple items, such as misaligned paper in a printer, can pose sufficient reason for a clearinghouse to reject a claim.
Most mistakes can be identified and corrected prior to transmission to the clearinghouse. It takes only moments to double check a claim before it’s sent, but correcting and resubmitting reimbursement claims can take hours of work and severely disrupts the flow of revenue. Knowing where the most common errors occur is the first step toward filing clean claims.