The Affordable Care Act has addressed some healthcare issues, but many of the common medical billing errors persist causing concern for healthcare providers, patients and the employers that ultimately sponsor health coverage for many in this country.
The first step to correcting medical billing errors is to define the underlying problems, so each can be assessed and corrected. In fact, many healthcare brokers and businesses are turning to companies like Copatient to navigate and negotiate medical bills for employers and employees.
However, once the medical billing mistakes are evaluated, additional work might be required to help resolve medical bill problems. Check out some of the top medical billing issues highlighted below:
Mismatched Diagnosis and Procedure Codes
Medical billing procedures require a diagnosis code and a procedure code. If the procedure code is not for an appropriate treatment based on the diagnosis code, the insurance company may deny the claim and refuse to issue payment to the healthcare provider.
Balance Billing
Once a claim from a provider on behalf of a patient has been submitted, the plan administrator will check to see if they have a contractual discount with that provider. If the provider does not have a contract with your network, the plan may make a payment that is considerably less than the provider is billing and the provider has no obligation to write off the unpaid balance. The amount left over, or the balance, is then billed to the patient. This is referred to as balance billing and can result in significantly higher bills for the patient than are typical for that service. These bills can often be negotiated down because the provider knows that the full charge rate is artificially high so it is always a good idea to try and negotiate these bills.
Unbundling
A medical billing code is associated with each service rendered by a healthcare provider. These codes may represent a single service or a set of related services that were performed. For example, several tests can fall under one code.
When the overarching treatment is broken down into several medical billing codes, and these codes are inappropriately billed separately, the error is referred to as unbundling. This error requires extensive coding expertise to uncover because the rules of which services should be bundled or unbundled when billing vary greatly by procedure.
Upcoding
When a medical billing specialist enters a code for a more complicated or costly procedure than the provider performed, it’s called upcoding. When looking for an upcoded procedure, it is important to refer to the medical record to compare the service that was billed to the service that was documented to ensure they are aligned
Timely Filing Limits
If a provider delays filing the claim for your services, they may end up losing their opportunity to reimbursed for that service. Many health plans have instituted timely filing limits so they may refuse a claim for services that happened outside of the time frame set. Many health plans also restrict providers from billing the patient for the balance when this happens, so if you’ve received a bill as a result of a provider failing to file a claim in a timely manner, you should refer to your plan documents because you may not be responsible for it.
Overlapping and Duplicate Claims
When various providers have billed for services performed on the same dates, your health plan may be on the lookout for overlapping claims. There are some instances where this is normal (for example, if you are in the hospital and you receive an X-ray on the same date that the hospital is billing for your overnight stay). There are other instances where this might indicate an error (for example, if a nursing facility and a hospital both billed you for the same night). When this error arises, check the medical records for documentation of services, dates and times to confirm the provider that should be reimbursed. Also, this is where your own notes can come in handy if you’ve been keeping track of your treatment.
Duplicate claims are exactly what they sound like; the provider may have inadvertently submitted the same claim twice. This is another situation where there are both valid and invalid claims so it is important to check the medical record to verify whether a service was truly delivered more than once and whether that was appropriate under the circumstances.
Non-covered Charges
A non-covered charge is not covered by a patient’s insurance company. There are typically two primary reasons for this; 1. The health plan has determined that the service was not medically necessary such as a cosmetic procedure, or 2. The health plan feels that the service is experimental and has not been approved for their members, such as an untested drug. Either of these determinations may be appealed but they may require substantial clinical knowledge to appeal. You may want to enlist the help of the provider who delivered the service in appealing these determinations.
In closing, the majority of medical billing errors are difficult to assess and can often represent costly consequences for people. However, they can be identified and, with a little work, resolved in most cases.
