Filing accurate and compliant medical claims is crucial for healthcare providers to get reimbursed for services rendered. However, medical claims processing is complex, and errors can easily occur, resulting in denied claims and lost revenue. Here are five of the most common errors found in medical claims and tips to avoid them:
1. Inaccurate Coding
One of the top reasons medical claims get denied is due to inaccurate coding. Medical coding translates services into universal medical code sets. Errors often happen when the wrong code is used or important details are missing. To avoid coding errors:
- Use certified medical coders who are up-to-date on the latest code sets and guidelines
- Perform internal audits to catch coding mistakes before submitting claims
- Verify codes match the documentation in the patient’s medical record
- Implement ongoing coding education and training
- Conduct coding quality reviews to identify problem areas
- Stay current on coding guideline changes and payer-specific policies
2. Incomplete Information
Insurance companies need complete patient and claim information in order to process and reimburse claims. Often required information is missing, such as the patient’s ID or birthdate, rendering claims unprocessable. Check claims carefully to ensure all necessary patient, provider, and service information is present before submitting. Also verify:
- Patient name matches exactly to insurance records
- Valid member insurance ID is used
- Correct provider identifiers and credentials are included
- Service location information is accurate
- Referral and prior authorization data is complete
3. Lack of Authorizations
Many services require pre-authorization from the payer before billing. Billing without proper authorization will lead to automatic denial of claims. Set up system edits during billing to catch any missing authorizations and get them before submitting claims. Doing so will dramatically reduce denials. Keep an updated list of services requiring authorization and verify they are obtained prior to scheduling.
4. Billing Errors
Simple billing errors like billing for the wrong date of service, duplicate claims, or charges that don’t match the services provided can lead to denied payments. Compare documentation thoroughly against what is entered during billing to catch discrepancies. Additionally, run billing reports to identify any duplicate claims. Implement claim scrubbers that will reject claims with obvious errors before transmission.
5. Untimely Filing
Insurance companies require claims be submitted within a specific timely filing period. Out of network claims, in particular, have more stringent timely filing limits. Mark calendars for filing deadlines and submit claims as soon as possible after date of service. For claims approaching deadlines, resubmit them as quickly as possible. Set up tracking reports to flag claims close to exceeding timely filing limits for priority follow up.
By being vigilant about these common claim errors, healthcare providers can reduce denials and realize the full reimbursement they’ve earned. For professional claims audit services, consider contacting experts like FRG for medical claims audit assistance. Proper medical claims management is vital for the financial health of every medical practice.
By being aware of the most common reasons for denials and putting expanded measures in place, healthcare providers can achieve higher claims submission quality and maximize appropriate reimbursement.
