Medical Billers Clean Up Claim Errors Before Submission

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Without a doubt, medical billers are the "clean-up" crew of the medical office. Medical billers are responsible for making corrections to the medical claim before it is sent out to the payers. Most of the time the information on the claim that requires "clean up" is due to errors made to the patient account through the different phases of the revenue cycle. Here are some common examples of information that is missed or inaccurate that could cause the payment to be delayed or denied.

Common Medical Claim Errors That Are Corrected Before Submission

  • Scheduling/pre-registration: Failure to obtain a referral and/or authorization for the visit or appropriate procedure. Simple inaccuracies in patient information can lead to billing denials. The smallest details are important to getting medical bills paid the first time. The front office staff can help reduce these denials by checking the details of the patient chart. Denials due to these inaccuracies can be re-filed, but instead of a 14-day payment turn around, it could take up to 30 to 45 days to finally get paid.
  • Admission/registration/check-in: Failure to enter accurate patient identification, demographics or insurance information. The number one reason why most medical billing claims are denied is a result of not verifying insurance coverage. Because insurance information can change at any time, even for regular patients, it is important that the provider verifies the member's eligibility each and every time services are provided.
  • Clinical: Failure to enter accurate information based on physician orders, medical history or medical necessity requirements. Many times this information is inaccurate due to misinterpretation or incomplete documentation. One letter missing from a word can change the entire meaning of it. Sometimes the physician only documents the basic information when more specific information is necessary, and someone may assume what he/she means instead of asking. This can result in conflicting information on the claim that could cause the claim to pay inaccurately or not at all.
  • Coding: Failure to apply appropriate modifiers to the matching procedure codes or failing to add accurate procedure and diagnosis codes to the claim. Coding claims accurately let the insurance payer know the symptoms, illness or injury of the patient and the method of treatment performed by the physician. Coding mistakes occur when the claim is submitted to the insurance company with the wrong diagnosis or procedure code on the claim. This may cause the claim to be denied for reasons such as no medical necessity or procedure does not match authorization.

Medical Billing Software to Catch Errors

Medical billing software is designed to catch many blunders that can have an impact on how a claim is processed or adjudicated by the payer. However, it doesn't fix those problems, but simply brings it to the attention of the biller in the form of edits or rejections. The biller is not only responsible for completing the claim by adding, updating or correcting the billing-specific information, but also for making sure all the other areas of the claim go out "clean."

Submitting Clean Claims

A clean claim is one that is accurately completed in accordance with the billing guidelines of insurance companies and the federal government. Since billers are the last hands that touch a medical claim, they are responsible for making sure that it goes out clean. Submitting a clean claim is the only way to guarantee correct payment the first time.

Medical office managers can do their part in making the biller's job a little easier in several ways.

  1. Purchasing real-time benefits verification software can save precious time by verifying a patient's insurance information at check-in time.
  2. Upgrade your old paper-based medical record system to the electronic health record (EHR).
  3. Keep the billing software pre-billing claim checks up-to-date with health care industry changes for billing, coding, and information specific to certain payers allowing staff to make proper corrections.
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