The Most Common Medical Billing Errors

When medical providers submit claims to insurance companies, a very precise coding system

must be used to represent the medical services the patient has received, so that the medical

provider can receive pay. Frequently, the person or persons responsible for submitting the claims

do not have coding certification to qualify them for accurately distinguishing between the

various codes. When mistakes are made, payments can be delayed or expire. When incorrect

information is submitted, the result may be in higher-than-expected charges and/or denials on the

claims from the insurance company. There are a number of ways that the medical provider’s

billing department may reduce their cash flow and the income of the facility. Some of the most

common medical billing errors are:

● Upcoding – This refers to the use of the wrong billing code so that the charge is made for a

more serious treatment or diagnosis than actually occurred. The result is often a higher

medical bill and this practice is against the law. Some examples include coding for hospital

care when outpatient services were used or coding for a name-brand drug when a generic one

was given.

● Balance Billing – Once the healthcare provider and the hospital have negotiated a price that

they will pay, the remaining amount that is not paid by the insurance is billed to you to

“balance out” the total. When the charges made by the hospital are covered under the policy,

balancing billing charges are illegal. The patient who received the medical services should

check with their insurance company to determine if the charges are covered.

● Unbundling – This term refers to the practice of listing charges separately when they are

normally listed under the same billing code. This often results in higher charges.

● Lack of Information – The information provided on the claim is used to determine the

diagnosis and the appropriate pay for that service. If the necessary information is not

provided, the insurance company may determine that the service was a “lack of medical

necessity” and deny your claim. The health care provider will typically end up charging you

directly.

● Incorrect Information – Instead of an omission of needed information to process the claim,

mistakes may be made that result in denial of the claim. A certified coder understands the

importance of going over the information to make sure the patient’s name is not misspelled

or that there are no other typographical errors. Considering that the information that is used

to file a claim passes through a number of hands, it is too easy to make these mistakes and

pass them on to the next person in an incorrect form.

● Diagnosis and Treatment Codes do not Match – This situation occurs when the diagnosis

is upcoded but the treatment code is not. In addition to being rejected by the insurance

company, the claim will likely be inflated due to the Upcoding, and you will be billed for it.

The importance of medical coding makes it imperative for any medical practice to have certified

medical billers who know which errors are most likely to occur, and who will work to prevent

them. The financial impact of multiple billing errors on the medical provider’s office can be

devastating, as can the result of denied claims on the patient who has received the medical

services. LS Coding & Education (cpc.certifiedcodertraining.com) offers the professional

medical coding classes that will bring your medical billers up-to-date on billing codes and

practices, to ensure a higher rate of payment for claims. The amount of cash flow that any

facility has from their claims will have an impact on the quality of medical care they are

prepared to provide. Supplies, salaries, and equipment are just some of the expenses that the