An important distinction in medical billing errors is the difference between a rejected claim and a denied claim.
A rejected claim is caused by a billing error that may result from a clerical error, or a mismatched procedure and ICD codes. These claims can then be corrected and resubmitted. Of course, correcting and resubmitting claims slows down the revenue cycle, cash flow, and also costs valuable time. The ideal is to submit clean claims, avoiding errors in the first place.
Most common medical billing errors
Here are some of the most common—and costly—billing errors that can easily be avoided when outsourcing your billing to an experienced medical billing company:
- Incorrect patient information – Sex, name, DOB, insurance ID number, etc.
- Incorrect provider information – Address, name, contact information, etc.
- Incorrect insurance provider information – Wrong policy number, address, etc.
- Incorrect codes – Entering confusing ICD, CPT, or HPCS codes; entering confusing Place of Service codes; attaching conflicting or confusing modifiers to HCPCS or CPT codes; entering too few or too many digits to an ICD, CPT, or HCPCS codes
- Mismatched medical codes – Entering confusing ICD codes with CPT codes, or vice versa, etc.
- Leaving out codes altogether for procedures or diagnoses – Failing to add proper procedures or codes for diagnoses is a surefire way to have a claim rejected.
- Duplicate billing – If the provider’s office submits a claim for a procedure that has already paid for or reported, this can cause a claim rejection as well.
- Provider initiated billing codes – Not all errors result from a biller’s errors. Some are the result of provider errors such as these, reports the American Medical Association:
- Undercoding – a provider intentionally leaves out a procedure code from a superbill, or codes for a less serious or extensive procedure than the patient received. Undercoding may be done to avoid audits for certain procedures or to try and save money for the patient. This process is illegal and counts as a type of fraud.
- Upcoding – Another fraudulent process where a provider intentionally misrepresents the work they performed on a patient. In upcoding, a practice enters codes for services a patient did not receive, or codes for more intensive procedures then the provider actually performed.
- Poor documentation – If a provider has provided incorrect, illegible, or incomplete documentation of a procedure or patient visit, it’s difficult to make an accurate or complete claim.
Common codes to avoid
In addition, inaccurate billing codes also put your facility at risk for denied claims. Here are some of the most common ones to avoid:
- 5HC01 results when the face-to-face contact required between doctor and patient is not verified.
- 56900 will appear when documentation for the Additional Development Request (ADR) is missing or late.
- 5HY01 occurs when the treatment or services are considered unnecessary or unreasonable.
- 5HC09 is related to the recertification order with an Additional Development Request (ADR) being denied because it is missing or incomplete.
- 5HC08 means that the recertification order for the estimated length of services is invalid, incomplete, or not present.
How home health providers can avoid costly medical billing errors
Unless you have experienced medical billing staff (and the budget to pay for a seasoned in-house team), it is difficult to avoid making these common billing errors or to know what denied claim codes mean. Proper claim submission can help you avoid these errors in commercial insurance billing.
Dominion Revenue Solutions can help you manage and minimize rejected claims so that your agency can receive the revenue it deserves. Prioritizing follow-up efforts is critical for commercial insurance claims. Let Dominion Revenue Solutions be your partner in these efforts to maximize your agency’s revenue.
