Top Five Medical Billing Mistakes

By Manny Sidhu


December 16, 2019

Given the fast-paced environment that medical officers are working in, it is no surprise that there are small mistakes here and there. The medical coding system is also complicated, which adds to why errors are almost inevitable. However, it does not mean that these mistakes are harmless. Payment delays, denial of claims, or even loss of revenue can all occur once these medical billing mistakes are not given immediate attention. Here, we list down five of the most common medical billing mistakes to look out for.

Medical Upcoding and Unbundling

Medical upcoding and unbundling is a rampant medical fraud that happens more commonly than you think. Upcoding involves passing off a patient’s initial diagnosis to a more severe medical condition. Once this happens, the fallacious medical condition will then require more expensive procedures.

Moreover, it can also happen when a patient is billed for a different service covered by the healthcare service provider rather than the procedure performed. On the other hand, unbundling is when a supposedly single code is separated into several different codes.

Double or Wrong Billing

As the name suggests, this is a simple human error made where there are two billings for a single procedure. It can also happen for booked medical services that a patient canceled but was retained in their account. Fortunately, in most cases, these errors are easily corrected once spotted.

Missing or Inaccurate Information

This mistake is one of the primary reasons for a lot of claim denials. It can easily be avoided by simply checking all the missing fields before passing a claim. Any missing or wrong information—name, birth date, sex, among others—can all be sources of problems. Again, this error is avoidable if the clerk is patient and meticulous enough to double-check and match the patient’s records and information. If medical billing professionals fail to further look into the disjunct between treatments, claim denial can happen.

Sometimes, the healthcare provider may be unable to provide the medical coding professional enough and accurate information about a diagnosis. When this happens, the bill will contain a mistaken medical diagnosis code. The insurance company will consequently deny the claim since this will reflect as a “lack of medical necessity.” In the end, the healthcare provider will directly charge the patient instead.

Failure in Insurance Verification

One of the most common causes for medical billing claims denials is simply because their insurance coverage is not verified. It’s important to note that insurance information can change at any time. Therefore, the healthcare provider must be able to verify the patient’s eligibility whenever they provide healthcare services. To further break it down, here are some insurance denial reasons:

  • The coverage of the member is already terminated or is ineligible for the medical service date
  • Unauthorized services
  • The plan benefits do not cover the services
  • Benefits are already maxed out

Failure to Review Clearinghouse Reports

Medical offices are understandably busy places, and this presents the challenge of accurately reviewing clearinghouse reports. However, ensuring that clearinghouse reports are checked is very crucial to know if there are problems in claims. When these are put on hold, the longer and less possible it is for problem claims to receive payment. Clearinghouse reports must become a priority at all times to prevent this inconvenience.

Prospa Billing for Your Medical Billing Services

Unfortunately, medical billing mistakes are growing more and more common. There may be a disjunct between medical coding professionals and healthcare service providers, which may be causing medical bills to inflate dramatically. Being knowledgeable about these mistakes and how to avoid them can help offices and patients save both money and time.

Similar to health, prevention is also a cure when it comes to medical billing errors. Much of these errors can easily be avoided just by double-checking and taking the extra mile to verify all information. If you need help with medical billing services, Prospa Billing can do the work for you. Contact us at (844) 663-3686 for further details. We look forward to helping you!

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