ERROR 1
Incorrect patient information / demographic errors / incorrect payer information
Missing patient information, incorrect address, date of birth, spelling errors, billing the wrong patient, assigning the wrong patient to guarantor.
ERROR 2
Inaccurate verification of benefits
Failure to check patient benefits by calling and speaking with a representative sets the provider up for failure. Policies that ensure accurate benefit verifications reduce denials.
ERROR 3
Understanding insurances — primary, secondary, supplemental
A patient cannot have two Medicare plans simultaneously. Medicare Advantage is primary when both cards are presented. Secondary plans cover gaps; supplemental plans typically cover Medicare deductible/coinsurance up to ~20%.
ERROR 4
Lack of obtaining authorization
Starts with accurate verifications. Knowing which codes and specialties require authorization under each insurance reduces denials.
ERROR 5
Documentation
Make SOAP notes mandatory and timely for new and seasoned providers. Include viable information that explains treatment. Insurers can ask for documentation at any point.
ERROR 6
Misuse or inaccurate DX codes
Inaccurate or deleted diagnosis codes drive denials, documentation requests, and audits. Newest ICD-10 deletions as of October 2024: M51.36 and M51.37. M54 codes with M51 codes on the same claim are exclusive and will deny.
ERROR 7
Use of incorrect modifiers
Most common errors: misuse of modifiers, or not using modifiers when needed (Medicare chiro / PT modifiers). Incorrect modifiers delay payment and trigger reviews, audits, and denials.
ERROR 8
Upcoding
Submitting a diagnosis or procedure more serious than what was evaluated — e.g., radiculopathy or disc degeneration when the patient has low back pain — or using a higher-level CPT than justified.
ERROR 9
Duplicate billing
More than one claim for the same service, patient, or date of service — including revised claims without correct info, billing a patient twice, same service multiple times in one day, or identical CPT from another practice same day.
ERROR 10
Corrected claims
Corrected claims are not for maximizing reimbursement. Use them to fix/add a modifier or correctly point a DX. Stamp “CORRECTED CLAIM” on the HCFA and explain the correction in Box 19 to avoid duplicate billing.
