Common Mistakes In Medical Claims And How To Avoid Them

Submitting accurate and compliant medical claims is crucial for healthcare providers to get reimbursed for services rendered. However, with complex coding guidelines and frequently changing payer policies, mistakes can easily occur. While honest mistakes don’t necessarily indicate fraud, repetitive errors will raise flags. Here are some of the most common medical claim mistakes and tips to avoid them:

Inaccurate Coding

Using inaccurate codes on medical claims is one of the most prevalent mistakes. Examples include:

• Picking the wrong CPT/HCPCS codes that don’t accurately describe the service provided
• Using codes for a higher level of service than what was truly rendered
• Failing to abide by coding guidelines like using codes not intended for outpatient setting

To avoid coding errors:

• Keep up with annual coding updates and guideline changes
• Ensure coders obtain sufficient education and training
• Have coders specialize in specific areas based on credentials to promote expertise
• Use coding audits to identify problem areas and provide feedback to coders

Missing Documentation

Another common claim denial reason is lack of supporting documentation. Payers require specific clinical notes, test results, and other records to validate claims. Missing documentation could indicate:

• Notes were incomplete or insufficient
• Records were misfiled or lost
• Documentation fails to substantiate the level of service billed

Best practices to avoid documentation problems:

• Educate providers on payer documentation requirements
• Perform internal audits to identify documentation gaps
• Use templates to ensure all elements are captured
• Scan records into EHR immediately to prevent misfiling

Duplicate Claim Submission

Sometimes billing errors lead to submitting the same claim more than once. Payers will reject duplicates even if resubmitted accidentally. This often happens when:

• Original claim was denied but no adjustments were made before resending
• Staff unknowingly submit the same claim multiple times
• Remittances showing claim status are not reconciled

Steps to prevent duplicates:

• Log all claims with tracking numbers and statuses
• Reconcile remittances against log to verify accuracy
• Adjust denied claims per payer instructions before resubmitting
• Use claim scrubbers to detect duplicates before transmitting

Errors In Patient Information

Inaccuracies in patient details like names, dates of birth, policy numbers etc. will also lead to rejected claims. This could be due to:

• Typos by administrative staff
• Outdated insurance information
• Filing claim under wrong patient record

Strategies for avoiding patient data errors:

• Verify all patient information at every visit
• Update insurance information frequently
• Use patient verification tools built into billing systems
• Perform internal audits to identify commonly misfiled data

Missed Deadlines

Finally, failing to submit claims on time will also lead to denials. Timely filing deadlines range from 30-180 days from the date of service depending on the payer.

Reasons for missed filing deadlines:

• Lack of initial notification of patient responsibility
• Administrative delays in claim preparation
• Errors that require correction before refiling
• Untimely follow up on pending claims

Best practices for on-time submission:

• Verify insurance eligibility at time of service
• File claims immediately once clinical documentation is complete
• Log claims with follow up protocols for pending statuses
• Set system reminders when approaching filing limits

How Medical Claims Audits Can Help

One of the most effective ways healthcare providers can improve claims accuracy and avoid common mistakes is through a medical claims audit. A qualified external auditor can identify problem areas by reviewing a sample set of your claims and documentation. The auditor provides specific feedback on where your claims and documentation are non-compliant and offers advice on corrective actions. This prevents future denials and ensures you are receiving optimal reimbursement.

You should have medical claims audited annually and any time major coding updates occur. Auditors typically offer pre-audit consultations to understand your specific needs. This allows them to tailor the audit, target high-risk areas, and provide the most useful recommendations. With the right auditing partner, you can proactively fix problem areas before payers flag them in an audit of their own. Audits also fulfill compliance requirements. 

By being aware of common claim submission mistakes and following best practices, healthcare providers can achieve cleaner claims with fewer denials and delays in reimbursement.

The owners of Cinnamon Hollow and many of its authors are not doctors and this is in no way intended to be used as medical advice. We cannot be held responsible for your results. As with any product, service or supplement, use at your own risk. Always do your own research and consult with your personal physician before using.

We are not lawyers and this is in no way intended to be used as legal advice . We cannot be held responsible for your results. Always do your own research and seek professional legal help.