The Most Common Denials:
Billing Error

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When physicians treat their patients, they must then select the appropriate procedure codes that represent the type of medical service that was performed.  These "procedure codes" are common in the health care/insurance industry and are referred to as "CPT" Codes.  Physicians must also select a diagnosis code to be billed along with the procedure code.  In other words, each claim submitted to a health plan must have accurate and distinguishable information on it so that when the health plan receives the claim it knows specifically what was done and why it was done.  From this claim information, a claims payment or denial is made.

However, as physicians spend many years learning how to practice medicine, not very much time is spent on teaching them how to bill.  This may lead to errors in billing.  A billing error is not necessarily an uncommon thing and could be easily rectified, as long as the correction of the claim is made promptly and within the timeframes given by the plan.  

Some common billing errors, include:

  1. Sometimes a modifier is billed along with a procedure code.  If the incorrect modifier is used, this could cause a claim denial.  A modifier explains special circumstances in the treatment of a patient.

  2. The physician may have selected the wrong procedure or diagnosis code on the claim, as explained above.

  3. The physician may have billed the wrong health plan, or billed with the wrong patient identifying information, including wrong social security or group/policy number.  This can also be easily corrected once the accurate health plan is identified by the patient and the charges are then billed to the new plan.

  4. Depending upon the type of plan, a certain health plan may require specific information on a claim, such as a physician participating plan or provider number. 

Billing Errors are primarily a correction of the original claim.  Some claims require the claim to be stamped "Corrected Claim" so that the health plan does not deny the claim for a duplicate claim.  However, sometimes a corrected claim may be questioned by the health plan to justify the change made in diagnosis or procedure code.