The Complete Guide to Fixing Common Medical Billing Errors

Here are some of the most pervasive issues derailing claims and reimbursements:

1. Inaccurate Patient Demographics
   Incorrect patient details like names, dates of birth, guarantor information, and insurance coverage cause headaches for practices due to mismatched data. Something as simple as a transposed date of birth or mistyped name can cause a denial or return to provider. Up to 25% of denials stem from invalid patient data per MGMA research.
2. Up-To-Date Insurance Information
   Outdated or inactive insurance ID’s are a recipe for denied claims. Make sure to verify patients’ coverage status during each pre-visit to prevent claims from bouncing due to non-covered services.
3. Missing Pre-Authorizations
   Many procedures, tests, and referrals require prior approval from the patient’s insurance plan. Claims will be denied without proper pre-certification documented, resulting in costly write-offs for providers.
4. Incorrect Modifiers
   Forgetting to include required modifiers like -25, -59, -RT, or -LT can cause denials for improper bundling. Healthcare organizations leave an estimated 2-5% reimbursement on the table due to improperly applied modifiers.
5. Invalid Provider NPI and Payer ID Numbers
   Claims get rejected when submitted with inactive or incorrect National Provider Identifiers (NPI) and Provider I.D. numbers for health plans. Ensure all internal systems and claims use current, valid codes.
6. Duplicate Billing
   Submitting claims for the same visit / service multiple times, or unbundling procedures that should be billed together, leads to denials. Duplicate billing can also violate fraud and compliance regulations.
7. Diagnosis Code Errors
   Using outdated or improper ICD-10 codes is a leading cause of denied claims. Specificity is crucial—be sure to code to the highest digit specificity to avoid unspecified codes.
8. Procedure Code Mistakes
   Submitting the wrong CPT, HCPCS or revenue codes misrepresents the services provided. Stay current with any annual coding changes such as deleted and revised codes using CMS and AMA resources.
9. Failure to Document
   Incomplete or missing documentation to establish medical necessity is a major risk area. Charts should always contain sufficient provider signatures, timed notes, and relevant patient information.
10. Timely Filing Deadlines
    Submitting claims past health plan time limits—often 90-180 days from the date of service— almost guarantees the claim will be denied. Track and enforce internal billing cycles to avoid untimely filing denials.

Common contributors include:

• Training & Knowledge Gaps
  Billing specialists need continuing education to stay current on coding regulations and changes. Missing expertise on medical billing requirements and payer rules is a risk factor.
• Outdated Payer Rules
  Insurance plans frequently update their claims processing edits and requirements. Providers must stay up-to-speed on health plan rules and proactively apply any modifications.
• Technology Limitations
  Many legacy billing systems and EMRs lack robust data validation capabilities. Hard-to-use platforms hinder productivity, causing more errors from manual work-arounds.
• Insufficient Quality Assurance
  Billers working solo without checks on their work are prone to make more mistakes. A two-pass coding system and other QA processes are critical.
• Staffing Issues
  High turnover rates or staffing shortages can increase per-biller claim volumes. Overloaded teams make more mistakes due to unsustainable workloads.

Despite solid processes and prevention efforts, billing errors still happen occasionally in any healthcare organization. But developing strategies focused on technology optimization, training, and quality control will help limit errors and related denials in the long-run.

Follow these proven tips from industry professionals to fix billing problems and tighten up your claims processing:

1. Improve Registration and Scheduling
   Registration and scheduling are the first lines of defense against inaccurate patient data. Train frontline staff on collecting complete patient demographic and insurance details during scheduling and check-in. Verify insurance eligibility and scrub claims data via real-time insurance verification tools and data interfaces. Develop standardized workflows for obtaining patient signatures on coverage documentation as well.
2. Manage Pre-Authorizations
   Engage in continuous collaboration between pre-certification staff, billers, providers and clinical departments. Track upcoming tests, procedures and referrals early on to ensure proper pre-approvals are in place. Leverage technology tools that help manage pre-authorization requests and approvals. Assign individual pre-auth responsibilities and timely follow-up tasks via billing software.
3. Conduct Regular Staff Training
   Invest in billing education resources to teach coding best practices and stay up-to-speed on regulatory changes. Make billing certifications a priority and promote ongoing credentials. Reinforce proper ICD-10, CPT, and modifier usage through case studies, audit reviews, and knowledge sharing. Facilitate peer coaching and mentorship opportunities as well.
4. Use Technology Tools for Coding Accuracy
   Combat coding errors by integrating billing software with computer-assisted coding engines and encoders. They can dramatically boost coder productivity, compliance and consistency. Leverage rule-based coding and scrubbing tools which automatically validate codes and modifiers against claims data. The instant feedback prevents avoidable errors up front.
5. Automate Claims Management
   Reduce human touch points and mistakes through RCM technology. Automation capabilities like claims status tracking, denial analytics and rules-driven workflows shorten billing cycles. Well-configured billing systems can also enforce important policies such as timely filing limits, accurately calculate patient financial responsibility, and streamline rejections management.
6. Follow a Two-Pass Coding Process
   Implement checks and balances through a second-level review process. Have a lead biller or coding auditor re-review samples of all outpatient or professional submitted claims. The double-check on coding, documentation, modifiers and charges helps catch mistakes before they reach payers. Standardized audit tools document error rates and enable retraining.
7. Monitor KPIs and Denial Analytics
   Track overall denial rates as a gauge of billing performance. Dive deeper into denial data with advanced RCM analytics to detect trends, bottlenecks and costly error hotspots. Keep close tabs on first-pass denial rates, timely filing percentages, modifiers per claim, and DNFB write-off amounts. Data-driven insights allow for targeted prevention and process fixes.
8. Tighten Security and Access Controls
   Make data protection and HIPAA compliance a priority through proactive cybersecurity action. Secure patient information and billing systems by limiting access on a strict need-to-know basis. Employ user-based permissions, audit logs, password best practices, and deactivate unused accounts routinely. Security measures protect data integrity and prevent unauthorized claims submissions.
9. Designate an Auditing and Appeals Expert
   Enlist a detail-oriented staff member to solely focus on billing audits, denials management and appeals. They should conduct routine internal coding reviews and drive prevention strategies. Denial subject matter experts are also tasked with accountability for overturning inappropriate payer rejections through meticulous appeals documentation and follow-up.
10. Refine Communication Workflows
    Collaborate cross-functionally between clinical, billing/coding and front-office teams. Foster an environment of transparency through standardized messaging channels like team huddles and ticketing systems. Clearly define hand-off processes for things like encounter forms, missing info requests, and rework tickets. These practices eliminate siloes and disconnects that breed errors.
11. Foster a Culture of Accuracy
    Develop a team mentality of individual and shared ownership in billing precision. Celebrate error-free days or staff members with excellent audit scores. Call out improvement opportunities compassionately. Leadership should make claims quality and revenue integrity organization-wide priorities through words and behavior. Boost morale while building an atmosphere of excellence.
12. Continuously Review Payer Rules
    Set up a system to track health plan claims edits, billing requirements, and coding updates. Assign owners to monitor and interpret new communications from clearinghouses and payers. Schedule periodic payer policy reviews with your billing staff. Open the dialog to resolve recurring rejections and understand claims processing changes on the horizon.