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These simple fixes could save thousands of dollars and dozens of headaches. Work them into your billing processes!
Is your treatment center experiencing financial difficulties? There are many billing errors that can cause claims to be denied. Payments being delayed, incurring fines, and revenue loss can all happen due to errors not being caught before submitting claims. So before you start sending your claims out, beware of the most common mistakes.
1. Forgetting to verify insurance
Believe it or not, the top reason why most claims are denied is because there was no initial verification of benefits and coverage. We all know insurance can change for whatever reason. So it is crucial that the provider verifies it every time services are rendered. When you don’t verify insurance properly, important details get overlooked, such as:
- The member’s coverage may be terminated
- The service isn’t even authorized in the first place
- The plan benefit doesn’t cover the service being rendered
- The plan’s cap on covered days, visits, or units has been reached
2. Inaccuracies in the Patient’s File
You would be surprised how something as simple as a patient’s name being misspelled, the wrong date of birth, an incorrect patient relationship status to the insured, or an invalid policy number can cause claims to be denied upfront. However, there are some pieces of information that aren’t so clear and easy to notice, such as:
- The claim requiring a group number to be entered
- Making sure the diagnosis code matches with the procedure code
- If there are multiple insurances, making sure the primary insurance is right for coordination of benefits
You don’t want to miss one of these simple pieces of information and turn what should be a 1-2 week turnaround into 30 to 45 days before the claim is paid.
3. Not Using the Correct Diagnosis, Procedure, and Revenue Codes on the Claim
As stated above, making sure the diagnosis and procedure codes match is very important, but more importantly you want to be sure the codes being used are actually correct. Keep in mind that revenue codes are not the same as CPT or HCPCS procedure codes: revenue codes identify the type of service or department on a UB-04 claim, while CPT and HCPCS codes identify the specific procedure performed, and payers expect the two to align. This is how the insurance company knows the symptoms, disorders and how they are being treated by the facility. Incorrect information can result in an immediate denial of the claim for not being medically necessary, or it doesn’t match the authorization given for treatment.
A couple of things to consider as to why the wrong diagnosis or procedure code could be submitted, resulting in denial:
- Your coding books are out of date and you’re using old protocols that have since been revised. Updated references cost money, but that is minor compared with the revenue lost to avoidable denials.
- If illegible handwriting on paper claims is causing denials, consider switching from paper to electronic submission.
4. Duplicate Billing
Duplicate billing is just what it sounds like: billing for the same service or treatment on more than one claim. It can also mean billing for a procedure that wasn’t performed in the first place. It is important to perform chart audits for all patients to ensure claims are being billed out correctly. Ultimately you want to eliminate these errors entirely, as facilities are fined each year for these mistakes, which can be treated as fraud.
5. Misrepresenting Level of Care
This occurs when the level of care is reported incorrectly in order to receive a higher reimbursement rate from the insurer, also referred to as up-coding. Claims are reviewed in fine detail, so it is not worth the risk; it will only lead to a denial and stall the claim payment.
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We work denials, appeals and underpayments for behavioral-health providers.