As we all know, most medical care today is paid for by third-party insurance, and the physician usually sends the bill directly to the insurance company. However, it is very easy for there to be errors in these bills, either in individual bills or in series of bills. These errors can lead to audits and other consequences to the physician. We have, therefore, set forth below some of the most common errors in physician bills to insurance companies.

Common Insurance Billing Errors

  1. Upcoding– Upcoding is when the medical billing code used is higher than the actual level of treatment.
  2. Unbundling – Unbundling is when charges that are customarily lumped together under one billing code are listed separately.
  3. Duplicate Billing– Duplicate billing is when procedures or services are charged more than once, such as a doctor and nurse both noting that a certain medication was given to the patient (such as an injection) without knowing that the other had already billed for the service.
  4. Lack of Medical Necessity – If the patient’s medical chart and billing documentation do not sufficiently describe and document the patient’s condition, your claim might be denied because of “lack of medical necessity.”
  5. Incorrect Patient Information– Any misspelling of the patient’s name or typo in his/her insurance ID can cause the insurance provider to reject the claim.
  6. Mismatched Treatment/Diagnosis Codes – This can occur when the diagnosis code(s) and the treatment code(s) does/do not match. For example, the bill may list the physician’s diagnosis as a respiratory infection, but the treatment code(s) billed include billing for a knee X-ray.

Georgia Health Care Compliance and Audit Lawyers

Chilivis Grubman Dalbey & Warner is a full-service healthcare law firm, and we are prepared to provide you with the knowledgeable guidance and strong representation you need for audit and compliance issues. Call (404) 233-4171 or contact us online if you need legal help with a healthcare audit.