1. Coding Errors: Incorrect coding is a frequent billing error. This can involve using the wrong Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes, incorrect modifiers, or mismatched diagnosis codes (ICD-10 codes). These errors can lead to claim denials, underpayment, or overpayment.
To avoid these errors, we recommend that the provider (or whoever codes for the provider) should be assigned to check all insurance companies websites for changes on a monthly basis. The insurance industry NEVER stays the same, it is constantly evolving. Signing up for email notices on policy changes from all the insurance companies can be very helpful in catching these changes ahead of time.
At Priority Medical Billing, Inc we do not provide coding services, however our billing staff's extensive experience, and access to resources, allows us to be able to recommend and assist our providers with any coding issues/questions they may have.
2. Missing or Incomplete Information: Incomplete patient information, such as missing demographics, email addresses, insurance details, or required documentation, can result in claim rejections or delays in reimbursement: To avoid this, PMB recommends to make sure on all new patients that all paperwork is reviewed by the healthcare provider at the beginning of the initial appointment to ensure the forms are all completed and all required information is provided and written legibly. On existing patients, providers or their office staff should confirm at each appointment the patients correct address, email address, phone number and insurance and provide the updated demographics to the billing company to keep the records accurate.
At Priority Medical Billing the most common reason for denials and non payment from insurance companies is “member not eligible”.
4. Upcoding or Downcoding: Upcoding involves submitting a claim with a higher-level service or procedure code than what was actually performed or documented, potentially resulting in higher reimbursement. Downcoding refers to using a lower-level code than appropriate, leading to lower reimbursement.
To avoid these denials or reduced reimbursement all medical providers need to be sure to know exactly what each insurance company requires to be documented in the medical records to prove that the services were billed as accurately and as specific as possible with the correct codes. Some insurance companies will go so far as to change the coding on your claim to “correct” the claim even though they do not have any of the medical records. Here at Priority Medical Billing, Inc. we do not accept these as complete payment, we investigate, request medical records, double check the codes billed and submit the claims for review or for an appeal if warranted by the medical records.
5. Unbundling: Unbundling refers to billing individual components of a bundled service or procedure separately, resulting in higher reimbursement than if the bundled code was used. This practice is often not compliant and can lead to audit findings or penalties.
All codes submitted on claims whether it is a CPT or ICD 10 code need to be coded to the utmost specificity for proper reimbursement.
6. Non-Covered Services: Billing for services or procedures that are not covered by the patient's insurance plan can result in claim denials and patient responsibility for the charges.
Office staff and Providers should know what services are reimbursable under each patients insurance plan. If a service is not covered by the patients insurance company then a solid “no surprise billing act” policy needs to be in place and all required forms signed prior to the service being rendered. All patients should also be required to pay, either in full or set up a payment plan for all charges associated with the non covered service, at the time services are provided
7. Past Timely Filing: Failing to submit claims within the required timeframe required by the patients insurance policy can lead to claim denials or missed reimbursement opportunities.
To avoid these denials, CMS guidelines and requirements are that all medical records should be updated either during or within a reasonable time thereafter. CMS.gov defines reasonable time as 24-48 hours after the appointment with the patient.
When these requirements are adhered to for all insurance companies and billing is submitted to the billing company then Past timely filing should never be an issue in a practice. At Priority Medical Billing, Inc, we encourage all our clients to have a solid double check system in place to ensure that patient encounters/visits are not overlooked or missed. PMB advises all our clients to submit all their billing to us by the end of each day and we will either have them submitted to insurance companies that same day or within 24 business hours.
8. Coordination of Benefits (COB) Errors: COB errors occur when the primary and secondary insurance information is not accurately reported or when the coordination between multiple insurance plans is not properly managed.
Sometimes these denials cannot be avoided. Patients are required to provide both their insurance companies with COB information. When a denial for this comes in, PMB sends a notice along with a statement to the patient asking them to contact their insurance company and provide them with the required information.
9. Inaccurate Charge Capture: Incorrectly recording services rendered or quantities of medications or supplies can lead to billing discrepancies and potential overbilling or underbilling.
Priority Medical Billing, Inc always recommends that double check systems at the office are in place to avoid any incorrect information. PMB keeps a look out on our end and will question our clients if a code or quantity doesn’t seem correct. We assist the office is finding the correct coding and quantities.
10. Lack of Documentation: Insufficient or inadequate documentation to support the services billed can result in claim denials or challenges during audits.
PMB will help our clients find the correct insurance company policies on documentation to ensure that medical records are being documented correctly prior to billing the claims.
It's important to note that these errors can have financial implications, affect reimbursement, and potentially raise compliance concerns. Implementing strong quality assurance measures, completing regular audits, and ongoing staff training can help minimize billing errors and improve revenue cycle management. Our staff at Priority Medical Billing, Inc is consistently attending webinars and educational seminars to stay on top of all the consistent changes in the health insurance industry.
If you are looking for a medical billing company that will help you stay informed, and avoid billing errors contact us via email at email@example.com or by phone at 708-362-6080.