Today more than ever, practicing medicine is a business. Practices need to be run with the bottom line in mind, just like companies in any industry. One of the quickest ways to put a practice's bottom line in peril is by committing billing mistakes. Unfortunately, there are a handful of billing mistakes that are far too common in health care.
Miscommunications between providers and coding professionals often lead to billing mistakes. These mistakes can become even more common when a practice decides to hire a third-party billing company as passing off the issue can breed further communication lapses, say experts.
Here's an in-depth look at some of the most common billing mistakes, how and when they occur, and what a practice can do to avoid them.
Common Billing Mistakes
A common billing mistake, medical necessity cases, is becoming more and more common, according to Brian Bewley, JD, a health care attorney at Bass, Berry & Sims PLC in Nashville, Tenn. Medical necessity infractions occur when a patient's condition doesn't warrant the services a practice bills for. For example, if a patient presented with stomach pain and a clinician ordered images of his right foot, medical necessity may come into question.
"There's not only a review of what you billed for, [payers] look at the medical records and the underlying condition of patients to determine whether or not the [billed] services meet medical necessity," says Bewley.
Another common billing mistake is the misuse of modifiers while coding, according to Michael Fossum, CEO of Nobility RCM, a Chandler, Ariz.-based company helping practices with financials.
A modifier is a code that physicians use to indicate that a service or procedure has been performed and altered by a specific circumstance, but has not changed in its definition.
"If the proper separation modifier is not put in place, or a discriminate procedure modifier is not put in place, the insurance company will recognize that multiple procedures were produced on one claim," says Fossum.
Modifiers, and coding in general, can be particularly tricky for small practices lacking the resources to hire a third-party billing company. Hiring a partner to perform billing and coding services is something Fossum says is strongly in due to the complicated nature of the process.
"It is such a time intensive and knowledge intensive process, you have to spend a lot of time on the billing and coding aspects of a practice," says Fossum.
A third common billing mistake that practices make has to do with up-coding (billing too much for the service provided), or under-coding (not billing enough).