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Healthcare Billing Errors

We will discuss how untrained staff and billing can affect your healthcare practice, affect legitimate billing companies and causing the costs to run these businesses to rise.

I truly take pride in the fact my business is staffed with trained professionals who are willing to continue their training, willing to learn new billing or credentialing software the provider chooses to use and that we are honest enough to say we are not familiar with an item but are willing to learn.

I'm noticing a lot of businesses are going to offshore companies to save money. However, are you truly saving money if you're having unnecessary mistakes that ends up costing your business in the long run?

The last part of my rant is from an experience I just witnessed. I belong to an awesome Facebook group that is dedicated to medical billers and coders that own their business. One person asked a question about how to coordinate benefits (primary, secondary, etc). I'd say 80% of the answers were absolutely wrong! They had no clue what or how to properly understand how to do this. I cringed when I saw this, because they are business owners responsible billing and coding for a healthcare practice.

Offshore medical billing. The allure of saving money is driving many healthcare providers to look to offshore companies.

Wanting to save money is not a bad thing. We all look for coupons, price compare, ask for references, etc. But when you're a healthcare provider, are you willing to risk your clients privacy, have fraud charges because claims are being created incorrectly or risk your reputation because your patients are being billed for services not actually provided?

HIPAA is a huge issue with offshore companies. Why? Because they're not bound by the laws we have in the United States. With HIPAA breaches, guess what's next? Identity and financial theft.

I've come across many articles regarding offshore medical billing and coding. Per LinkedIn (,

Offshore Billing

An offshore agency is a legal entity formed in a jurisdiction other than the investor’s own. The reason for this offshore incorporation is because offshore jurisdictions can provide beneficial tax treatment in the form of reduced or even zero taxation. One of the main advantages of offshore coding is that it is available around the clock and on weekends. Organizations can move their coding operations to a 24/7 operation using offshore coding, minimizing swings in discharged-not-final-billed. Another significant advantage of offshore coding is the cost reduction. Offshore services are usually less expensive than those offered in the United States. Some other advantages are as below

  1. Privacy – An offshore company isolates you from your business, assets, and liabilities as a separate entity.

  2. Confidentiality – This may be the most significant distinction between onshore and offshore businesses. The company’s specifics, as well as the controlling shareholders, are kept hidden from the general public. Unless a criminal inquiry is underway, no one’s identity will be revealed.

  3. Taxes – Non-resident corporations are taxed differently in most offshore countries. In these nations, offshore firms enjoy a special status that exempts them from local taxation. There is likewise no tax on overseas earnings or capital gains.

Let me explain, I'm NOT against all offshore medical billing and coding businesses because there are many that are fantastic. I'm stating this is for the ones that are more concerned with money that accuracy, privacy and ethics.

Untrained and/ or confused staff

Untrained staff is another reason for healthcare billing and errors on the rise. Not only can this cost a practice money due to denials, but it can also put a practice at risk for criminal charges of fraud.

I've witnessed firsthand "billers" or "coders" not knowing the basics of healthcare billing or coding. I've seen people asking what is coordination of benefits, what is a modifier, how to verify insurance of a patient, etc. That's very concerning. If you don't know the basics, then handling businesses finances is probably not a good idea.

I used to think, if they don't know the basics, then how did they pass their certification exam. After speaking to a few training schools, it seems some of them "pass" students due to quotas. Like, what? Seriously? Yes, I'm afraid so. I've also seen ads where companies are saying, "You can own a Medical Billing and / or Coding Business with No Experience" and people are actually signing up for this. To see how frightening this is, google "how to become a medical biller without going to school". Even worse, google "how to own a medical billing company with no experience". Because I don't want to get sued for slander, I will not name those schools or websites.

My opinion, if we require healthcare providers to get credentialed, maybe we should do the same for medical billers and coders. I'm a biller and administrative person and I'm more than happy to prove my knowledge of the healthcare field.

"Private practice physicians face enormous pressures. Among the biggest stressors today is the business side of healthcare, especially concerning medical billing and coding. The complexity of the medical industry can take precedence over the treatment of medical conditions in determining the sustainability of a medical practice.

Medical billing errors result in billions of dollars in incorrect payments and loss of revenue for the healthcare system. Physicians walk a fine line when submitting payments to Medicare and other third-party carriers. The probability that a medical claim will contain errors is high. New levels of specificity in coding and the addition of pay-for-performance measurements have taken reimbursement woes to a new level. The rule of thumb is if it is not documented, it did not happen.

No matter how many bells and whistles the EHR has, providers cannot rely on technology to make correct coding decisions.

Denials often are an indication of failure to understand correct coding guidelines and payer contracts. Physicians rely on their billing staff to handle claims effectively and efficiently for proper and timely payments, requiring them to stay current with regard to changes to medical codes, claims management, and proper billing protocols. Reimbursement problems most often stem from failure to follow strict coding and billing practices and lack of proper reimbursement training. These rules are updated frequently. Inexperienced staff or failure to stay up-to-date with proper billing protocols that may vary by payer and may leave a trail of denials or improper payments.

Pay-for-performance and quality measures have added layers to the reimbursement process. A lack of continuing education and software training has a direct effect on the cash flow and profits of a practice. The importance of a trained staff cannot be overemphasized. Well-trained coders and billers pay dividends when it comes to positive cash flow and overall profitability of the practice."

The 5 Most Common Billing Errors

  1. Failure to Very Patient Insurance

  • A quick phone call or look on the patient's insurance portal is all it takes to verify if the patient's insurance is still active.

  • When you contact the insurance, you're able to physically see (or hear if you call):

*If coverage has been terminated

*If the maximum benefits has been reached

*What services are not authorized

*If a copayment is due

2. Incorrect Codes are used

  • Using incorrect ICD-10 or CPT Codes can cause billing to be denied. Also using incorrect modifiers can cause denials.

  • Undercoding

*Caused when the biller fails to bill the insurance the entire range of services given to the patient. This can cause loss of revenue.

  • Overcoding

*This means the biller or practice has exaggerated it's services to the patient in order to be reimbursed a higher rate. Do this can also cause legal issues for fraud and / or abuse

3. Inadequate or missing details of services

  • This occurs when the bill is submitted to the insurance company with not enough information being provided to show a medical necessity

  • This can also go with the undercoding example above

  • Each diagnosis should be coded correctly and showing the diagnosis explains the reason for the procedure and / or evaluation

4. Timely Filing

  • This is defined as "when you file a claim within a payer-determined time limit. For example, if a payer has a 90-day timely filing requirement, that means you need to submit the claim within 90 days of the date of service"

  • Some insurance companies require claims to be filed between 90 days and 1 year. It's up to the biller and practice to know the timely filing of the insurance companies they're billing

5. Human Errors

  • Entering the wrong patient demographics is a huge error that can be prevented. Before submitting a bill, review that the information you inputted is accurate and up to date. It takes a few minutes to review

  • Forgetting to add a modifier is another human error that's preventable. If you're not positive of what modifier to use, then either look it up or ask, but please don't leave it blank if you know a modifier is needed

  • Putting the incorrect provider information

*missing or incorrect NPI number

*listing the provider as the rendering provider instead of the referring provider

These are just a few examples of medical billing and coding errors. I can go for hours explaining the importance of proper medical billing and coding and what can happen when done incorrectly. But, I'll save that for another blog idea.

Please take the time to read some of the links to the articles that I've mentioned.


Until We Meet Again...

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