The ultimate goal of revenue cycle management companies is to ensure that healthcare professionals get paid totally and fulfill their revenue reimbursements without any halt.
Focusing on the goal isn’t that easy while they have to confront billing errors both human as well as electronic which are mostly unavoidable and unprecedented. The major part of medical billing process in revenue cycle management companies is reduction of errors.
What could common errors in medical billing practice of revenue cycle management companies be? Well, we can explain it in detail.
First and foremost, let’s learn about differences between Denials and Rejections of submitted claims.
Denials and Rejections of Claims:
- A denied claim is not similar to the rejected claim.
- For a rejected claim, the errors are found before processing the claim by the insurance companies.
- It stops the reimbursements for the healthcare professionals and returns to the billing team of revenue cycle management companies in order to correct those claims and resubmit them.
- Usually rejected claims are caused due to clerical errors or irrelevant diagnosis procedures and ICD codes.
- These rejected claims are resent to the medical billing team of revenue cycle management companies to explain the errors and resubmit them after corrections.
- The final goal for the revenue cycle management companies and clearinghouse is a “clean” claim.
- Whereas denied claims are found after the claims are processed by the insurance companies with vital errors that may violate the terms and conditions between patient and insurance companies.
- The insurance companies will give a clear explanation of the error and return the claim to the billing team of revenue cycle management companies for corrections.
- There are chances to appeal and send back these claims again to the insurance companies for processing but it can take time and therefore can also be costly.
- However, it’s important to go forward with the clean claims in one go without any time lapse in the billing procedures that are irreconcilable for patients.
What do you think simple errors are?
- After a brief discussion on rejected and denied claims, it’s evident that errors are the main reason for resending the claims to the billing teams of revenue cycle management companies.
- Those simple errors can be:
- Inaccurate patient information
- Inaccurate healthcare provider information
- Inaccurate insurance provider information
- Incorrect medical codes
- Incompatible medical codes
- Missing out the codes of diagnosis and procedures
- Duplicate Billing
1.Inaccurate patient information:
- Patient demographic details such as sex, name of the patient, ID number, DOB etc are incorrectly entered and submitted in the claim before sending it to the insurance companies.
2.Inaccurate healthcare provider information:
- Healthcare provider’s information is also as important as patient information because each patient’s diagnosis depends on the individual provider who has rendered services.
- Healthcare professionals’ information such as address, name and contact information is very essential for the claim submission and to prevent denials.
3.Inaccurate insurance provider information:
- Entering inaccurate policy numbers, wrong addresses can cause lot of issues in processing the claims. Revenue cycle management companies must ensure to send correct policy numbers and cross check the details before submitting the claims.
4.Incorrect Codes:
- Inaccurate ICD, CPT or HCPCS medical codes with confusing place of service and different modifiers can make the claim return to the billing team of revenue cycle management companies.
- Also entering too many digital codes those are irrelevant for a claim can cause trouble and create claim rejections.
5.Incompatible medical codes:
- Confusing ICD codes, CPT codes can put healthcare professionals at risk while they find trouble with frequent denials and rejections.
6.Missing out codes of diagnosis and procedures:
- Leaving the diagnosis and procedure codes while submitting a claim is not acceptable as they are very crucial for processing the claims.
7.Duplicate Billing:
- It is when the medical billing team or the healthcare professionals’ staff submits a claim without checking if the service has been paid or reported.
- This creates a huge confusion between the payers and medical billers as the claim shows two identical procedures or diagnosis on the same day.
- Apparently, the amount sent to the insurance companies doubles the actual amount to be paid for the services rendered.
What does Complicated Billing Errors do?
- These errors can be critical and get out of medical biller’s hands, regrettable . They are very important to watch out for.
- Under coding
- Up coding
- Poor Documentation
- No proper EOB on Denied Claims
1.Under coding:
- Under coding occurs when the healthcare professional leaves out the diagnosis and Procedural code intentionally or leaves codes for extensive procedures than the patient had received.
- Under coding mostly occurs while trying to avoid audits and trying to save money from the patient side. It’s considered to be illegal and fraudulent act.
2.Up coding:
- Up coding is also an illegal and fraudulent act just like under coding.
- Up coding occurs when the healthcare providers purposely misinterpret their performance and enter the codes for the services patient didn’t receive.
- This act is done in an attempt to collect more revenue from the insurance companies for the services not rendered by the healthcare professionals.
- These kinds of fraudulent practices must be noticed and reported immediately.
3.Poor Documentation:
- While this cannot be counted under fraudulent practices but can affect the claim process negatively with the poor documentation submitted to the insurance companies.
- If the healthcare professionals provide inaccurate details of the patient or procedure or the policy, it’s very difficult to make a correct claim and complete the revenue payment process.
- In the cases of poor documentation, the medical billing team from the revenue cycle management companies should verify with healthcare professionals and get more important and essential information.
4.No proper EOB on Denied Claim:
- There are certain cases where the insurance companies forget or fail to attach Explanation of Benefits (EOB) for submitting the claim.
- In such cases, the errors are notified lately and become a difficult task for the medical billing team of revenue cycle management companies to move further for an appeal process.
Hope you got the information on potential billing errors. For suggestions, please comment below. We will surely consider if relevant. For more queries and updates on healthcare please subscribe to our blog.
