Identifying and Addressing Common Medical Billing Errors
Background
ClaimDOC’s comprehensive line-by-line review of claims uncovers errors that basic claim repricing and auto-adjudication does not catch, leading to greater savings for health plans and its plan members. Our audit team analyzes all types of healthcare claims for a variety of potential concerns, including excessive usual and customary charges, duplication of claims, incorrect coding, unbundling of services, and many others. Our claims review is not intended to impact care decisions or medical practice.
In this Claims Audit Spotlight, we focus on identifying and addressing common medical billing errors identified as part of ClaimDOC’s claims analyses and related pricing. As healthcare costs continue to climb an upward slope, there is an escalated need for healthcare payers to reduce overspending resulting from medical billing errors and improper claim payments.
Case Scenario
A 60-year-old male underwent outpatient surgery at a hospital in Kentucky for the treatment of foot pain and tendonitis.
The hospital submitted a UB-04 claim form/electronic equivalent, which included charges for HCPCS code C1713 defined as, Anchor/screw for opposing bone-to-bone or soft tissue-to bone (implantable) with quantity units of twenty-eight (28) and related charges of $67,150.54 for these implants.
Other hospital charges on the claim included surgery, diagnostic tests, pharmacy, and recovery room, totaling, $58,174.56.
Medical records were requested from the hospital to review/verify the number of implants used/inserted during the operative procedure with comparison to the number/quantity units of twenty-eight (28) charged and billed by the hospital.
Our review of the operative report and corresponding implant log identified while twenty-eight (28) implants were reported/billed, the medical record documentation supported sixteen (16) implants were used/implanted, which consisted of plates, screws, and wires.
The unit cost for each implant (HCPCS code C1713) was $2,398.23. Our analysis supported an overage of twelve (12) quantity units billed, resulting in hospital overcharges of $28,778.76.
Total Hospital Billed Charges $125,325.10
ClaimDOC pricing $17,051.49 based on the hospital’s cost-to-charge ratio (C-C/R) with markup.
Plan Savings: $108,273.61
Percentage of Savings: 87%
The Takeaway
The incorrect quantity of units for implants was reported and billed on the above hospital claim. While hospitals may charge any amount they elect for items/services provided, incorrect reporting of services, egregious fees and coding/billing errors can complicate matters for members to understand their bills and payments, impact the collection of patient balances, build a reputation of facilities charging high fees, create burdens for patients having no insurance and a host of others.
Given the volume of healthcare claims that are reported/billed each day by providers/suppliers, it is a given – errors in medical bills are alarmingly common. Discrepancies in quantity units billed and quantity of units furnished to the patient is a common occurrence, specifically as it relates to:
- Implants used and quantity units billed
- Medication dosage administered and quantity units billed
Inaccurate and erroneous medical bills cost everyone, even healthcare providers. Billing/coding errors can lead to improper payments, payment delays and impact revenue flow.
When an individual receives a healthcare bill that appears questionable/inappropriate, an inquiry to the provider and/or health plan should be made to obtain an explanation of the service(s) and corresponding charges.
Our goal at ClaimDOC is to use benchmark charges and costs nationally to negotiate fair and ethical payments. Our high-quality, expert review of claims identifies and prevents improper medical claims payments and maximizes cost savings opportunities. Employers turn to us to establish fair reimbursement rates for their plans allowing them to save money and provide richer benefits to their employees. A win-win for everyone.