(908) 222-0002

9 Medical Billing Errors That Will Enrage Your Patients

9 Medical Billing Errors That Will Enrage Your Patients

Medical coding and billing are an important part of modern medicine. Someone visits a doctor or healthcare facility, and after the visit, their insurance is billed. As the healthcare world changes to meet new government regulations and the separation of healthcare providers and medical coders grows, so does the miscommunication and the billing errors.

Medical billing in New Jersey, as well as other states, sometimes happens outside of the medical facility where the care took place. With medical billing companies and medical coding and billing jobs from home becoming more and more common, accuracy without direct communication is imperative.

Why Patients Get Angry

Patients get angry when errors cause them hardship. Hardship can come in many forms. Some errors may force a patient to spend hours on the phone. For many patients, errors can also result in economic hardship. A patient may end up paying for what their insurance won’t cover or paying for services they may not have really received when billing errors are present.

Making multiple phone calls, spending time on the phone rather than working or being with family, and being hit in the pocketbook are some of the potential costs of medical billing and coding errors. These errors cause annoyance and dissatisfaction with providers and their staff.

Avoiding errors is the best way to maintain a good patient-provider relationship, and this portion of the responsibility lies on a medical coder. Due diligence is the way to produce the best billing documents you can and avoid time-consuming and costly errors for all parties involved.

1. Balance Billing: When You Can and When You Can’t

Why is Balance Billing a bad idea?

Balance billing is a tricky thing. There are times when it is illegal, and other times when it’s required. There are some cases where health plans can sue out-of-network providers for not balance billing their patients.

This type of billing is also legal when the health plan doesn’t have a contract with the provider or if the services the patient received aren’t covered by their insurance. Other times, such as when it’s a covered service and when the insurance has a contract with the provider, this practice can be illegal.

What to Watch Out for:

Not knowing the law and not verifying what a patient’s insurance covers can cause issues here. It’s best to know before you bill.

2. Diagnosis and Treatment Code Mismatch

When you learn how to become a medical biller, you learn that diagnosis and treatment codes must match. This mismatch can be particularly bad when an upcode is involved because the insurance company will reject it and the patient will be responsible for additional costs. When the patient finds out about the error, they will be furious. The error wastes their time, and may even waste their money.

What to Watch Out For:

Upcoding a diagnosis code, but forgetting to match the treatment code. These two codes always need to be reviewed to ensure they match, since insurance companies will reject claims with mismatches.

3. Not Verifying Insurance Coverage

Verify insurance coverage

Insurance coverage on conditions, treatments and procedures varies widely. As a medical coding specialist, it’s your job to verify a patient’s insurance coverage. The patient’s coverage can change at any time, and the patient may not know about it. This step will prevent problems before they start.

What to Watch Out for:

Don’t skip steps in the process. Always validate patient insurance coverage.

4. Unbundling Services

Services cannot always be billed as separate services. Sometimes a series of services will actually 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.

What to Watch Out for:

Single tests and services performed together that belong together under one code.

5. Duplicate Billing

Duplicate billing is particularly stressful for patient and yet easily avoidable

Duplicate billing is when a patient is billed for the same service more than once. There are many ways this error can be made. A doctor or nurse can be at fault for this billing mistake when both request that a patient be charged for a prescription or service.

Other times, this is the result of the patient being billed for multiple “first days” in the hospital. This type of error is particularly irritating to patients and can cause them to spend many hours on the phone trying to get this remedied.

What to Watch Out for:

The same service appearing multiple times from separate providers, or more than one “first day” billed during the same hospital stay.

6. Entering Incorrect Information

This faux pas is one that is often cautioned against in medical billing education. However, whether you’re a seasoned pro or you’ve had your medical billing certification for a day, you’re equally susceptible to this mistake.

Misspellings and/or typos in the address, account number, birth date or other identifying information can lead to problems. Some errors, like typos in the insurance ID, will result in the claim being rejected. Rejected claims are upsetting to patients, and can lead to complaints. Nip these errors in the bud by double-checking patient information before you press send.

What to Watch Out For:

Typos in any vital information, but especially the patient’s name, insurance ID and any related account numbers. A quick double-check can save hours of trouble and avoid claims being denied.

7. Providing Medical Necessity

When a physician fails to give the coder accurate information, lack of medical necessity occurs

Anoto AB / Flickr / CC BY-NC-ND

Lack of medical necessity is 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 and in turn, the patient’s insurance company may deny the claim, specifying “lack of medical necessity.”

What to Watch Out for:

Billing without enough information for a particular diagnosis. It’s important to ask physicians for clarification when necessary in order to bill appropriately for services.

8. Upcoding

Upcoding is when the patient is billed for services they have not received or services that were more extensive than those that were actually executed. This can happen for one of two reasons. The first reason is accidental; it can happen when the diagnosis and treatment codes don’t match.

The other way upcoding can occur is when a provider knowingly misconstrues the procedures that were performed. Upcoding is done in an attempt to receive more money from the payer. This practice is also illegal and should be reported.

What to Watch Out for:

Mistakes that create treatment and diagnosis code mismatches unintentionally cause upcoding issues. Always double-check codes to make sure they match. If the information that the provider gives doesn’t make sense, ask for clarification. In the case of misrepresenting information, this type of behavior should be reported.

9. Undercoding

Undercoding is not just illegal – it's immoral

A bill is undercoded when the patient isn’t charged for all procedures completed. Undercoding is illegal and can be considered fraud, so billing accuracy is vital. There are other times where a provider may intentionally attempt to undercode so that they can avoid audits or save a patient money. This type of behavior is fraudulent and illegal and needs to be avoided.

What to Watch Out for:

Missing procedures in the billing process leads to the bill being coded inappropriately. Always review the superbill, as well as the chart, to confirm that every procedure is billed for.

Preventing Errors

There are many things a medical coder can do to prevent errors. A coder should always double-check a patient’s address, date of birth, medical record number, insurance ID and 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 steps like insurance verification. They are an important part of the process. You must carefully perform research in the chart and try to find all of the medical conditions that a provider has treated a patient for during the visit. Coders also need to ask for clarification when details aren’t clear, so that each condition is billed for appropriately and accurately.

Even when you’re sure you’ve done things right the first time, it’s always important to perform a double-check. Read through the claim and make sure there are no errors before you send it. This second check will often prevent you from making simple mistakes.

When it comes to confirming insurance coverage, make sure you get all of the necessary details. Some of the things you’ll 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

Continuing Medical Billing Education

The best way to confirm that you’re doing your job correctly is to keep up to date with medical coding laws, trends and industry updates. Medical billing and coding classes don’t end when you get certified. You will also need to complete continuing education credits to stay up to date and certified.

It is recommended that new medical coders join the American Association of Professional Coders (AAPC) to stay on top of their profession and find continuing education credits for their certification. Keep tabs on your industry with professional magazines and websites. Newsletters and email mailing lists can be valuable resources for linking you with industry trends and other industry professionals.

If you’re looking for a place to learn medical coding, AIMS provides a premier medical billing and coding program in New Jersey.

  • Pingback: How to Make Insurance and Benefits Verification a Better Experience for Clinics and their Patients - Dental Insurance Verification()