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The "Clean Up" Crew

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Without a doubt, medical billers are the "clean up" crew of the medical office. For those that do not understand this concept, medical billers are responsible for making corrections to the medical claim before it is sent out to the payers. Most of the time the information on the claim that requires "clean up" are due to errors made to the patient account through the different phases of the revenue cycle. Here are some common examples of information that is missed or inaccurate that could possibly cause the payment to be delayed or denied.

  • Scheduling/Pre-Registration: Failure to obtain a referral and/or authorization for the visit or appropriate procedure. Simple inaccuracies in patient information can lead to billing denials. The smallest details are important to getting medical bills paid the first time. The front office staff can help reduce these denials by checking the following details of the patient chart. Denials due to any of the inaccuracies above can be refiled but instead of a 14 day payment turn around, it could take up to 30 to 45 days to finally get paid.

  • Admission/Registration/Check-in: Failure to enter accurate patient identification, demographics or insurance information. The number one reason why most medical billing claims deny is a result of not verifying insurance coverage. Because insurance information can change at anytime, even for regular patients, it is important that the provider verify the member's eligibility each and every time services are provided.

  • Clinical: Failure to enter accurate information based on physician orders, medical history or medical necessity requirements. Many times this information is inaccurate due to misinterpretation or incomplete information documented. One letter missing from a word can change the entire meaning of it. Sometimes the physician only documents the basic information when more specific information is necessary and someone may assume what he/she means instead of asking. This can cause conflicting information on the claim that could cause the claim to pay inaccurately or not at all.

  • Coding: Failure to apply appropriate modifiers to the matching proceducure codes or adding accurate procedure and diagnosis codes to the claim. Coding claims accurately lets the insurance payer know the symptoms, illness or injury of the patient and the method of treatment performed by the physician. Coding mistakes occur when the claim is submitted to the insurance company with the wrong diagnosis or procedure code on the the claim. This may cause the claim to deny for reasons such as no medical necessity or procedure does not match authorization.

Medical billing software is designed to catch many of "blunders" that can have an impact on how a claim is processed or adjudicated by the payer. However, it doesn't fix those problems but simply brings it to the attention of the biller in the form of edits or rejections. The biller is not only responsible for completing the claim by adding, updating or correcting the billing specific information but also making sure all the other areas of the claim go out "clean".

A clean claim is one that is accurately completed in accordance with the insurance companies and federal government's billing guidelines. Since billers are the last hands that touch a medical claim, they are responsible for making sure that it goes out clean. Submitting a clean claim is the only way to guarantee correct payment the first time.

Medical office managers can do their part in making the billers job a little easier in several ways.

  1. Purchasing real-time benefits verification software can save precious time by verifying a patients insurance information at check-in time.
  2. Upgrade your old paper-based medical record system to the electronic health record (EHR).
  3. Keep the billing software pre-billing claim checks up-to-date with health care industry changes for billing, coding and information specific to certain payers allowing staff to make proper corrections.
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