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
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