Up to 80% of all medical bills contain mistakes, so what can be done to fix this problem?
Up to 80% of all medical bills contain mistakes.
This alarming figure was deduced by the Access Project, a Boston-based health care advocacy group, and is close to what many health experts have been saying in recent years. Furthermore, Kaiser Health reported that $68 billion in lost healthcare spending can be attributed to medical billing mistakes.
Mistakes result in loss of reimbursement so the practice loses revenue. Secondly, and a potentially costlier problem, is that when it comes to Medicare billing, the federal government and Office of Inspector have “zero tolerance” for any inadvertent errors, fraud or abuse. A practice can be prevented from billing Medicare or Medicaid services for years if it is found negligent.
David Womack, president and CEO of Practice Management Institute, notes the risks are not just financial, as consequences of medical billing errors can even result in harm to a patient. A failure to bill correctly may affect a patient’s treatment due to an incorrect diagnostic code that could lead to improper patient care at another practice.
“Companies offering professional certification in medical coding, third-party billing, office management and compliance are helping set a higher standard in employment by providing up-to-date education and testing that assures each applicant’s complete understanding,” he says. “The result being that physicians can focus their attention solely to patient care, translating to a better experience for the patient, all while ensuring the practice continues to be successful.”
Jim Leonard, director of healthcare business development at GRM Document Management, a records-retention and management service, says problems with billing are less an issue of errors than attempting to file a claim with unverified information.
“The smaller a practice or facility, the more likely things are overlooked, resulting in unpaid or underpaid claims and a less robust financial picture,” he says. “Many specialized companies exist to manage the revenue cycle for smaller or less sophisticated healthcare organizations.”
Joseph T. Jenkins, MD, a general surgeon with FACS of Tri-State Vein Center in Dubuque, Iowa, does all of his practice’s billing in-house and says billing errors may include under-coding or over-coding for an office visit.
“We all make mistakes transposing CPT codes wrong or ICD-10 codes wrong or putting on the wrong modifier,” he says. “Those are easy to rectify. Usually the insurance company comes back letting you know you did something wrong.”
The way he has reduced errors is by using software that helps generate the note and check items within the HPI, ROS, PFSH and physical exam, keeping track of where he stands with meeting the different levels of care provided.
“I am then only responsible for selecting the appropriate Medical Decision Making,” he says. “The system will give me a Level of Service Code.”
Elvira Kasimova, billing department supervisor for the WCH Service Bureau, says the problem of billing errors is acute at both small and independent practices.
“The combination of busy doctors and undertrained staff results in inaccurate billing, requiring superbills to be returned to doctors,” she says. “Practices often fail to ascertain the correct insurance coverage and making sure that their services are determined to be medically necessary under the patient’s insurance coverage.”
An ineffective compliance plan or one that the office doesn’t adhere to is often the culprit for mistakes resulting in billing and claims problems. Practices often fail to conduct regular training about coding and billing updates and other changes.
Kasimova says another way mistakes happen is due to improper communication, such as a physician or staff member not relaying the correct information to a provider concerning things like eligibility and coverage.
Every practice should have a compliance plan and policy as well as someone responsible for enforcing it, Kasimova says. Either the medical director or a staff member should function as the compliance person.
“It is important that written policies and standards assist with potential risk areas like billing, marketing and claims processing,” she says. “Failing at implementing those rules leads to miscommunication between doctor and the rest of employees-especially front desk-and as a result, it increases the risk of inaccurate coding and billing or claims being submitted to federal programs or to other insurances with mistakes that can cause red flag and pre-payment/post-payment reviews/audits.”
Jenkins says that staff should have continuing education and training to maintain compliance and get updated on new coding and billing issues. Practices can also conduct periodic internal monitoring and a billing audit, which will identify problem areas of their work and where they should pay attention in the future.
Also, it wouldn’t hurt to have an impartial, third-party billing expert retained to evaluate a portion of the claims to ensure there aren’t problems among a staff member or how bills are being submitted.
Remember, letting an error go is worse than anyone making a mistake or two. Employees need to know that they can report an error and that doing so is considered a positive, rather than a negative.