5 billing mistakes to check for in your practice

Small billing mistakes rarely announce themselves. Each one below shows up as a pattern in your reports, and each has a fix you can start this month. The first three are practitioner checks rather than findings from a study. The last two lean on published rules and benchmarks.

1. Upcoding and unbundling

Upcoding means using a billing code that pays more than the code that reflects the service furnished. Unbundling means using separate billing codes for services that have an aggregate billing code.^[4] Both are compliance risks. In its 1998 guidance for billing companies, the HHS Office of Inspector General called upcoding a major focus of its law enforcement efforts and noted that HIPAA added a civil monetary penalty for it.^[4] The definitions say nothing about intent, so either can also result from a coding error.^[4]

How to spot it: compare a sample of billed codes with the visit notes, and look for providers whose code mix shifts without a change in their patients. How to fix it: have a certified coder or a second reviewer check a monthly sample, and give providers feedback on documentation gaps.

2. Incomplete or wrong patient information

If the name, date of birth or member ID on a claim does not match the payer's records, the payer may reject or deny the claim.

How to spot it: look at your clearinghouse rejection report for demographic and member ID errors. How to fix it: check details against the card and a photo ID at check-in, and re-verify them at each visit, because coverage changes.

3. Skipping eligibility checks

Verify coverage before the visit so you know whether the plan is active, what the copay is, and whether the service needs prior authorization. Learning any of that after the visit leaves you correcting a claim or billing the patient instead of preventing the problem.

How to spot it: look for denials citing inactive coverage or a missing authorization. How to fix it: run eligibility for the next day's schedule each afternoon, or hand the work to insurance verification services.

4. Missing timely filing deadlines

Timely filing deadlines are set payer by payer. Medicare's rule is that a claim must be filed no later than the close of the period ending one calendar year after the date of service, with limited exceptions.^[3] For commercial and Medicaid payers, check the contract or provider manual for the limit. As a hypothetical example, under a 90-day limit a visit on January 10 must be billed by April 10, even though Medicare's own limit would still be open.

How to spot it: look for unpaid claims in your oldest aging buckets with no follow-up notes. How to fix it: keep each payer's deadline on a rule sheet and work the aging report weekly. Steady AR follow-up works claims before they age out.

5. Weak denial follow-up

Denials only help you if you learn from them. HFMA describes an industry average denied-claim rate, by dollar value, of 5% to 10%, with under 5% as optimal.^[1] MGMA DataDive reported 8% of claims denied on first submission for single-specialty practices in 2023 data, a count of claims rather than dollars.^[2] As an illustration, on $60,000 of claims submitted in a month, a 5% rate means $3,000 denied and a 10% rate means $6,000.

How to spot it: if you cannot state your denial rate by payer, start there. How to fix it: log every denial by reason, fix the cause at the source, and appeal the denials worth appealing. That is the core of denial management. If you are weighing outside help, read what outsourced medical billing costs. To see where your own claims stand, request a free billing audit.