It doesn’t matter whether a medical biller is brilliant, or how brilliant they are; while working on daily claims all day, it’s only human to have some claims get downright rejected. Sometimes, it’s the medical insurance company at fault; at other times, it’s because some vital information got left out.
To not let the latter happen to you, these are a bunch of important questions you should be asking yourself…
Did you check if the patient information was both accurate and complete?
It is imperative that you fill in patient information that is correct as well as complete. Making silly mistakes, such as spelling the patient name wrong, or writing the wrong date of birth, messing up the subscriber number, and so on could make it impossible for the health insurance plan to identify the right patient, and therefore make the payment.
Did you file your claim on time, or not?
You’ll find most companies giving a period of 60 to 90 days, starting from the time of service, to file a claim. But, if you take too long to file, after the date of service has passed, it’s likely to get rejected.
Did you check for proper Procedure and Diagnosis codes?
For CPT code (procedure) and ICD-10 code (diagnostic) that are found to be missing, or invalid, or incomplete, or not corresponding to the treatment as suggested by the physician, the insurance company is bound to deny the claim. As the changes to HCPCS are made periodically, one needs to stay updated on any codes being either added, or revised, or plain discarded.
Did you get your plan pre-authorized?
Many plans (like HMO, PPO) demand a prior authorization, in absence of which, the medical billing claim gets rejected. Also, there are certain non-covered services or exclusions, which just like the name suggests, are not included in the health insurance coverage of a patient. To render such services, the patient needs to remember that will have to pay the whole cost from their own pocket.
Did you acquire a referral from your physician?
Not just mere authorization, but there are medical plans (Like HMO) that require the patient’s doctor or PCP (primary care provider) to give a referral before any service can be rendered to them.
Did you run out of authorized sessions?
Once you’ve been granted authorization, you have to remember, it is only for a limited number of appointments or services. Keep a track of appointments carefully, or you might end up taking sessions that you won’t be getting paid for.
Did you check whether or not your authorization timed out?
Not just for a particular number of appointments, but the authorization you take is also valid for a specific amount of time. The time frame could even be as short as 30 days or depend on the insurance company. Therefore, be mindful of the duration authorized to you, or you could have your medical billing claim rejected.
Did you send your claim to the wrong insurance company?
You’ll find insurance companies delegating the management of some of their medical plans or certain services within such plans, to other third-party companies. If you fail to realize this, and accidentally send the claim to anyone but the managing company, and/or if you failed to check the eligibility and benefit of patient insurance, you should get ready to have your claim be denied or rejected.
Did you know that the out-of-network benefits are different from the in-network ones?
These are two distinct sets of benefits, which one needs to be aware of. Such as, a company would place greater responsibility on the patient that would include the potential for extra deductibles to be met when it comes to out-of-network benefits. If one fails to identify the exact amount that a patient owes for the out-of-network services, they may just never get paid for the work they do. For some plans (like PPO and EPO), there are no out-of-network benefits or less.
Did you make sure there isn’t a case of duplicate billing?
If one resubmits a claim, instead of following up, or canceling a test or procedure, and not simply removing it from the patient account, a case of potential duplication could arise. Only through proper coding of service, complete with the apt service modifiers would make a claim identify itself as an original, and not a duplicate.
Did you indulge in malpractices, such as Upcoding and Unbundling?
To use a higher-paying service code on a claim so that one receives greater reimbursement on a covered service, usually in place of a not-covered service, is called Upcoding; and it is considered a fraudulent practice. Another illegal practice is Unbundling or Fragmentation, under which a person submits their bills piecemeal so that they can get as much reimbursement as they can, for the procedures that are actually meant to be billed together. If one gets caught indulging in such malpractices, there’s no way but for their medical billing claim to get plain rejected.Leave a reply →