It's time to declare war on costly billing mistakes

Coders, billers, and physicians are much more knowledgeable now than when we started working with practices over 25 years ago. There has also been a steady increase in automation throughout the billing, documentation, and coding process. Despite the increase in knowledge and increased use of automation, we continue to see many costly billing, documentation, and coding mistakes. 

In this article, we will review mistakes made throughout these processes and what you can do to prevent them.

Billing errors common

Access Project, a health care advocacy group, has determined that 80% of all medical bills contained mistakes, according to an Aug. 2, 2017 Medical Economics article, “Easy tips for physicians to reduce billing errors.” Kaiser Health reported that $68 billion is lost to health care spending because of medical billing mistakes.

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Billing rules and payer requirements have become more and more detailed and restrictive. The margins within which physician practices operate continue to decrease. Electronic medical records, practice management systems, and other automated tools used by practices require too much time and manual effort to use correctly. New quality and value programs are requiring more time and effort with little visible benefit to patient care or outcomes.

The health care field is in many ways no different than the broader market. As the system becomes more complex, practices have to continue to innovate, educate, and improve internal systems to keep up with both the clinical and administrative demands of the system. Like it or not, human interface is a key component. Input into the system must be accurate, and the outcome of the automated processes must be monitored to ensure that the information is correct. “Garbage-in/garbage-out” is applicable to today’s medical billing process.

In our work with practices around the country, we see mistakes being made in every step of the complicated and detailed process. Collecting patient data, identifying the services provided, accurate service documentation, determining the correct codes, submitting the claim, and accurate follow-through are a few of the common failure points in the process.

Today’s billing process requires a team effort in every practice. Many of you are familiar with what we’ve called the “Wheel of Fortune” detailing the 18 to 20 steps that are required to accurately code, bill, and collect.

Next: Common points of failure

Common points of failure

Here are just a few examples of areas and actions that we see as common points of failure during the billing process.

Pre-service: Incorrect demographic data, inaccurate insurance/coverage information, prior authorization. Solution:

• Attention to detail by practice staff, including collecting all required information, scanning documents, and entering data correctly and in the correct fields.
• Leverage all available tools: Understand your practice management system, upgrade when required, conduct routine training, find external tools and plug-ins to address deficiencies, analyze performance, and provide feedback to your team.
• Collect before or at the time of service any co-payments, co-insurance, and past due balances. Setting proper expectations is half the battle. Communicate with your patients and provide accurate and complete information.
• Be patient and be diligent, but move forward.

Encounter: Failure to report all services provided, incomplete documentation, inadequate communication from provider to billing department, and inaccurate coding, including the wrong level of evaluation and management service provided. Solution:

• Proper and consistent communication, including feedback among clinical and administration, is required.
• Double checks in the protocol are a must. Do not rely solely on your EMR code (E/M) calculator. Review coding-both manual and automated-regularly, with a focus on accuracy. Both upcoding and downcoding should be addressed through training.
• Understanding of service coding is beneficial for both data input accuracy and output accuracy. Lead by example; a physician who does not care about coding accuracy may be perceived as not caring about billing accuracy. Your staff will follow your lead. Online video and in-person seminars targeted to physicians are available from the AUA, Physician Reimbursement Services Network, and other sources; use them all.
• Continuous training of billing staff and clinical staff, including quick reference material, such as the “Pocket Card” and auacodingtoday.com, are invaluable. Use multiple sources and assess both learned and retained information.

Billing: Improper modifier use. Two specific examples follow.

Example 1: Modifier –25 is both overused and underused due to a lack of understanding of how it should be used. Solution:

• Updated, accurate, practice-wide policies and training to promote consistent application and understanding of proper use are essential for both data input (chart documentation) and output (coding and billing).
• Understand payer-specific requirements for use of this modifier relative to diagnosis and service combinations.

Example 2: Modifier –59 and the “X” modifiers. The problem here is overuse and misuse. Solution:

• Practice-wide policies and training to promote consistent documentation for services that may require use of modifier –59 or –X (E, S, P, U) modifiers should be implemented.
• Billing staff, including certified professional coders, will need to continue educational updates and obtain practical experience with payers for each practice.
• Consistent communication pathways among clinical and administrative staff should be developed to include messaging and meetings with specific, targeted agendas.

Next: Follow-up

Follow-up: Automated posting is not an excuse to allow payers to process claims without review. Solution:

• Do not assume the payer is correct.
• Analyze non-paid claims and payment level for each service.
• Correct and resubmit mistakes made by office for payment.
• Medicare has made it clear when denying a claim that the agency is sending a message and does not expect practices to keep making the same mistake. When claims are denied, they should be appealed to demonstrate the mistake was Medicare’s or billing staff should communicate office errors to prevent future errors and then either reprocess with corrections or appeal with documentation.
• Do not fall behind. Lack of claims follow-up is a compounding error and timely follow-up is well worth the effort. Attention to detail, even on small claims, adds up quickly. PRS  contracts to work accounts receivable projects for multiple practices around the country with excessive A/Rs due to lack of time, staff, and/or neglect. Many of the unpaid or underpaid claims can be systematically identified, repaired, resubmitted, and collected.

In summary, physicians, as leaders of the team, need to be more knowledgeable and more involved, and pay attention to the details. In addition, they need to demand excellence in education and performance by their entire team. Conducting periodic checkups is required. Being too busy taking care of patients and ignoring the business you run can be very costly.

Read: When can modifier –25 be used with an E/M code?

Physicians are very trusting and hire people that they know have the expertise to do the job. They don’t question their expertise or the jobs they’re doing. This is a good thing in many ways. However, to quote W.C. Fields: “Trust everyone, but cut the cards.” Each employee must be held accountable for their actions. The office needs to know that everyone who touches the many steps in the revenue cycle has the knowledge, expertise, and understanding of the tools and expectations to do their job. In addition, staff members should be encouraged to update and continue their education.

We encourage you to look at your data entry, documentation, billing, and collections in depth throughout the year. Whether you own the business or are employed, are “hands on” or are detached from the billing process, you are ultimately responsible for bills submitted in your name. The battle to end billing mistakes will require continued analysis, diligence, and leadership.

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The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

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