Medical Billing is a challenging job. The necessary attention to detail to create codes based on diagnoses, then bill insurance companies based on these codes requires a great measure of patience and care. According to the American Medical Billing Association's director, Cyndee Westonthe, the job growth in the industry is projected to increase by 30 percent over the next decade.
There's also the chance of displeasing a patient; as the American Institute of Medical Science and Education states in their article 9 Medical Billing Errors That Will Enrage Your Patients, patients are upset by errors that cause them hardship, such as wasting time making multiple phone calls rather than working or being with family, and being hit in the pocket with unexpected costs. These errors also cause annoyance and dissatisfaction with providers and their staff.
To maintain a good patient-provider relationship, it is necessary to avoid errors as much as possible. Due diligence is the way to produce the best billing documents you can and avoid time-consuming and costly errors for all parties involved.
Common Billing Issues
The 9 Medical Billing Errors listed below are the most common, and can create displeasure to your patients:
Balanced Billing: Sometimes You Can and Sometimes You Can’t
Balanced billing (the practice of billing a patient for the difference between what the patient's health insurance chooses to reimburse and what the provider chooses to charge) is a tricky thing. There are times when it is illegal, and other times when it is required.
It is considered illegal when services are covered and the insurance company has a contract with the provider. On the other hand, it is legal when the health plan does not have a contract with the provider or if the services received by the patient are not covered by their insurance.
There are also some cases where health plans can sue out-of-network providers for not balance billing their patients. Not knowing the law and not verifying what a patient’s insurance covers can cause issues. It is always best to know before you bill!
Diagnosis and Treatment Code Mismatch
Not Verifying Insurance Coverage
Sometimes a series of services will all fall under one billing code. Charging these services as separate services rather than billing them as a single service is known as Unbundling. This can make a patient’s bill much higher than it should be.
Entering Incorrect Information
Misspellings and/or typos in the address, account number, birth date or other identifying information can lead to glitches in the billing process. Some errors, such as typos in the insurance ID, will result in the claim being rejected which leads to upset patients and complaints. These issues can be prevented by double-checking patient information before sending the claim.
Not Providing Medical Necessity
Lack of medical necessity occurs when a physician fails to give the coder accurate information on a patient’s diagnosis. This may prompt a wrong code to be used when billing, which usually results in a denial of such claim.
The use of proper software tools can reduce billing errors even without enough information for a particular diagnosis. This is usually achieved by associating the proper codes to the clinical notes and diagnosis introduced by the physician into the same system.
Always double-check codes to ensure they match. If the information that the provider gives does not make sense, ask for clarification. Misrepresentation is illegal and should be reported to prevent possible confusions or prosecution.
Missing procedures in the billing process leads to the bill being coded inappropriately. Superbills should always be reviewed, as well as the chart, to ensure that all procedures have been accounted for.
There are many things that you can do to prevent errors. You should always double-check a patient’s address, date of birth, medical record number, insurance ID, other identifying information, as well as ensure that all CPT and ICD-10 codes are correct. You should also verify that the diagnosis and treatment codes match.
Never skip the insurance verification step as it plays a very important part in the process. You must carefully perform research in the chart to ensure that all of the medical conditions that a provider has treated a patient for during the visit are accounted for. You also need to request clarification when details are not clear, so that each condition is billed for appropriately and accurately.
It is always very important that a biller or coder double-check their work to ensure that there are no errors. This second check will often prevent simple mistakes. There are many tools that can assist with checking, if details are missing.
It is always best to ensure that all the necessary details are garnered in confirming insurance coverage. Some of the things you will need to know are:
- If the insurance company mandates preauthorization.
- The co-pay and deductible.
- Limitations on visits and coverage.
- Maximum coverage for the particular procedure.
- The address claims should be sent to.
Keep Up-to-Date with Regulatory Changes
Our first recommendation for Medical Billers and Coders is to stay up to date on new mandates and regulatory changes. This is key to guarantee swift claim payments and reduce time spent on returned claims attributable to errors. Becoming a biller can be overwhelming due to the amount of information that must be garnered. The best way to do this is by subscribing to several important email lists so the information comes directly to you. These include:
- The Medicare email list and newsroom page. Medicare sets the industry standard for other insurers.
- The ICD-10 email list
- The major insurance carriers' policy and claims information. All major insurers post this information online for billers to use, and your doctor's tax I.D. number will gain you entry to the information.
- The social media accounts for national coding and billing organizations, such as the American Medical Billing Association (AMBA) and the American Academy of Professional Coders (AAPC), where you can scan regular updates to get educated on upcoming changes.
Please note that the change in coding from the International Classification of Disease ICD-9 to the ICD-10 coding system took effect on October 1, 2015.
Become Fluent in an Industry Software
Fifty-four percent of offices are completely electronic in their record keeping, according to HealthIT.gov, and electronic healthcare records (EHR) are the industry standard. Navigating both digital and written records creates room for error. Software applications, such as MedEZ™, are common in many medical offices. Get to know how to use these software applications; they are real time savers.