Healthcare billing is a multifaceted and crucial process for the fiscal operations of healthcare providers. Yet errors are all too pervasive, resulting in denied claims, decreased reimbursements, financial hardship, and patient discontent. While a few mistakes originate from technical malfunctions or system constraints, human errors also contribute extensively to problematic billing. Medical billers and coders need to have comprehensive attention to detail, an understanding of continuously changing payer requirements, and meticulous record-keeping practices to sidestep common pitfalls. Perfecting these skills enables staff to submit precise claims with supporting documentation the first time.
The Most Frequent Errors
According to recent surveys on medical billing errors, the following mistakes are those which most habitually lead to rejected claims:
- Missing critical patient information – Lacking patient details on forms like names, date of birth, insurance policy numbers, etc. can halt claims in their tracks, especially for government-funded programs. Failing to get patient consent or authorization also leads to denials.
- Inaccurate medical codes – Entering wrong medical codes, like a CPT procedure code or ICD diagnosis code, is one of the most common errors. Coders must select codes which match the clinical documentation. Missing a secondary code can also lead to a rejected claim.
- Outdated/expired payer policies – Payer policies continually get updated, meaning requirements change often. Using outdated information leads to non-compliance. Staff must read payer bulletins and stay on top of new technology, coverage criteria, authorization protocols, etc. Content must match coding.
- Untimely claims submission – Most payers have strict time limits for claims submission, usually between 90-180 days from date of service. Submitting outside of these windows means automatic denials. Tracking deadlines helps prevent late submissions.
- Improperly documented services – According to the good folk over at Find-A-Code.com, billing for services without documenting medical necessity or failing to record procedures in a timely fashion leads to rejections. Proper medical coding displays value. Durable medical equipment (DME) claims often face scrutiny too.
How Staff Can Prevent Mistakes
In order for billers and coders to minimize mistakes like those outlined above, they need a robust mix of human skill and technical tools. Key proactive strategies include:
- Developing and maintaining proficiency in payer requirements and effective compliance programs, including regular policy reviews and testing. All office staff should understand critical billing regulations and how to capture necessary information upfront to avoid later issues. Annual training is key.
- Consistently reviewing and reconciling all patient and claims data prior to submission to verify nothing gets missed or input incorrectly, like missing signatures, name differences, inaccurate units of care, etc. Use checklists or problem logs to track common issues. Document medical necessity too.
- Updating billing systems and software to catch and prevent vulnerabilities. Program safeguards can detect discrepancies, monitor timelines, and flag potential denials during secondary internal claim audits. Activate features to ensure submitted codes are valid together. Update fee schedules regularly.
- Improving front-end data collection processes enables back-end billing success. Verify insurance eligibility benefits early. Ensure complete patient documentation with detailed histories.
Staff should also adopt standardized protocols for handling denied claims. Rather than reviewing rejections haphazardly, set up a systemized approach. Analyze reasons for denials to identify patterns and problem areas. Categorize by payer, error type, frequency, etc. to better target solutions. Track appeal success rates as well. This metric data then feeds back to improving overall claim accuracy by revealing where to focus compliance efforts for maximum impact.
Conclusion
Of course, despite best efforts, some billing mistakes will still slip through the cracks. When caught, billers should make prompt corrections and resubmit denied claims when eligible. Consistent monitoring and problem solving ensures optimal revenue cycle management. Preventing errors is challenging but pays dividends.
