How to Recover from Medical Billing Claim Errors - dummies

How to Recover from Medical Billing Claim Errors

In medical billing, claim errors result in either rejections or denials and overcoming these can be challenging. Reimbursement is a direct result of the provider’s tenacity in following up the claim submission and submitting the claims correctly.

How to overcome rejection

With a rejection, essential information is missing from the claim that prevents the payer from entering the claim into its system. Common reasons for rejection include missing or incorrect patient identification number or demographic information such as sex or birth date. Your goal with a rejection is to provide the missing info in a thorough and timely manner.

If a claim doesn’t process correctly as result of a coding error, you need to submit a corrected claim. Many payers have specific forms that you must use to facilitate this process. Usually the form asks for the original claim number and includes a field you use to identify the reason for the corrected claim submission.

If you notice that a claim was coded or billed incorrectly, it’s the provider’s responsibility to notify the payer of the error. Failing to notify a payer when a claim has been erroneously submitted may result in charges of fraud. Other types of fraud include knowingly submitting incorrect information or filing a claim for services that were not provided.

In some cases, the payer may request a refund of the incorrectly billed claim. Medicare has a voluntary refund form on the Centers for Medicare & Medicaid Services (CMS) website, as do most carrier websites.

This form is used when a provider wants to return a Medicare payment, and it allows the provider to simply submit a new claim. Commercial payers vary in their policies when dealing with an incorrectly submitted claim, so check with the individual payer to verify the process prior to sending back a payment.

How to deal with denial

With a denial, the claim went through the provider but is not being paid for some reason. Claims deny for a myriad of reasons, such as omission of policyholder information (name, birthdate, and relationship to patient) when different than the patient, failure to obtain an authorization number or referral, not checking the “Accept Assignment” box, or missing or incomplete provider information, such as the physical address where services were rendered.

When you’re faced with a denial, you don’t take it lying down. Instead, you gather together your wherewithal, your documentation, and anything else you need and file an appeal.