Are Your Billing Errors Costing Your Patients?

Season #1


Are Your Billing Mistakes Costing Your Patients Money?

Hi, everyone, welcome back to Revenue Cycle Decoded where we are cracking the code on revenue cycle issues. Today, I just wanted to riff a little bit on a topic that kind of chaps my hide a little bit, and that topic is billing errors that are costing your patients money or time.

So, let’s get started with this topic. The reason that I wanted to talk about this topic today is that I just received a bill from my dentist. Of course, dentists are not fun in the first place, at least not usually, but getting a bill is even more not fun. You want to be billed accurately from your dentist, and unfortunately, this bill was not accurate. So let me tell you a little about it.

I went to the dentist and had a cleaning and received the bill. I’m in network. My health plan is in network, the dentist is in network with my plan, I should say, and so they submitted the claim to the health plan. The EOB came back to the dentist with a denial for one of the services that was billed for the reason it cannot be billed on the same day as another service that they also billed for.

So, lets’ break that down. If there is an administrative denial on a claim because two services can’t be billed together on the same date of service – that's an administrative denial – you can’t then go and balance bill your patient for that according to your contracts with your payors. Unless, you know, it’s something that is not normally covered by the payor and you’ve received the patient consent to cover that, that’s a different story. You have to explain to the patient that this is a service that isn’t normally covered by the payor and therefore if the patient wants it to be performed, then they would be responsible to pay for it; they sign a consent stating that they are going to be responsible for that service and then you can balance bill the patient. But in this case, it was an administrative denial, the reason being that the code itself – the HCPCS code – specifically states that it cannot be billed with the other service on the same date of service. It’s the intent of the code.

So, they had seen the denial on the EOB but they had added back the portion for the denied service onto my patient responsibility and sent me a statement for that amount. Now because I am a certified coder and a certified biller, I immediately questioned, “why am I being billed for a service that was denied?” I looked up the codes so I understood exactly what I was being billed for, and I also looked up their professional association guidelines from the American Dental Association and found that there is indeed a specific guidelines for these two codes which states that because of the code definition of one of the codes, they cannot be billed together on the same date of service and it recommended other codes that can be billed for an exam, for example. Then, I also contacted my payer to make sure that this was an administrative denial and that I was correct that the dentist cannot bill.

So, the good news is, I did call my dentist and talked to their front office person who will forward my concern to her manager, but interestingly, when I discussed the issue with the claim, she stated, “We’ve never had somebody bring this up before.” Now that gives me a bit of a pause because that tells me they may be routinely billing these two codes together and patients who are not certified coders and certified billers may not understand the reason that they are getting balance billed and they may just be paying the bill. In other words, they may be paying something that they really, legitimately don’t owe and the fact is that the office is incorrectly billing them and it’s costing the patients money, or at the very least, time, as it did me, to look up the error and inform the office of the error.

Hopefully, the next statement that I get, the error has been corrected and the amount has been adjusted off. But this is why it’s important, first of all, for patients to look at their claims and understand what they’re being billed for, but as we all know, patients are not billers or coders. They don’t know the byzantine rules that we live by. That is why, as a practice manager, it falls on you to make sure that your billing staff and your coding staff understand the codes that you’re billing and what’s going on the claims. They need to know any edits that apply to the codes, they need to know any policies, regulatory guidelines, medical policies, clinical guidelines, utilization guidelines, local coverage determinations and articles, all of those different payor guidelines – authorization requirements, anything that has to be met before they will approve the code – your staff needs to understand that. This is why it’s important to have professional coders and billers on your staff or at least someone who is very, very aware of the codes and what their definitions are and all of these things that go into whether or not the code is payable. Otherwise, your patients, who don’t know all of this, could be inaccurately billed and they could be paying you what has been dropped to their patient responsibility when really it should not have been because it was a billing error by the office.

This isn’t the first time this has happened to me. A few years ago, I had a screening mammogram done, and according to my health plan, screening mammograms are covered at 100%, so imagine my surprise when I received a bill from the hospital for the screening mammogram for the full amount. When I received the EOB from my health plan, it had denied the service for not meeting medical necessity.

Okay, now hopefully, if you have a patient that this happens to, they would question it, they would call up the billing office and say, “Why was this denied because it’s a screening mammogram and it’s supposed to be covered?” and someone would look into it. And that’s what I did. But you may have many, many patients who do not know to do that and would just pay the amount thinking, “Oh, okay it must have been denied for some legitimate reason and I’m just going to pay it.” Or even worse, they don’t pay it, they don’t question it, they just look at the bill and think, “Oh my God, I can’t afford that!” and just don’t pay it. And we know, we have lots of patients that for whatever reason don’t pay their bill and don’t communicate. And in this case, because they don’t question their bill, you may not be looking at it either. So they could end up getting sent to collections for a medical bill that they legitimately do not owe.

In my case, once I called, and we dug into the problem, the provider had put a primary diagnosis of essential hypertension on the claim which of course didn’t meet medical necessity for a screening mammogram. they had to go back and re-code and resubmit the claim. These are the kinds of billing errors that can end up costing your patients. It may cost them in time – just the time to look up and call you and sit on the phone and try to figure out what’s going on with the claim because it is wrong and they know it’s wrong or it’s costing them in money because they are paying for a claim that they really don’t legitimately owe, or they are getting sent to collections again for something that they don’t legitimately owe.

Just to reiterate for the episode today – how important it is to be an advocate for your patient in the billing process. Not only is it important for us to educate our patients about what their responsibility is and what they will owe for services they will receive, but it’s also our responsibility to be a patient advocate in making sure that our billing is correct to the very best of our ability. Now, I know we are human, things get past us, right? But we need to understand, like I said, the code definitions, the policies, the edits, the requirements, the authorization requirements, etc., etc. We need to understand that. We are the professionals here. We are the ones who are supposed to understand the billing and coding piece of our practices. So I just want to remind you to remind your billers and coders, double check those claims. Run them through the scrubbers, run them through the edits, make sure that the diagnoses make sense, have someone actually looking at the documentation before you are coding and billing out those claims. Make sure the information is correct. This is such an important piece of the revenue cycle, but It’s also so important for your patients. Be your patients’ advocate today. Make sure those claims are correct.

Thank you for listening to my rant today. I would like to invite you to join me in the Facebook group Revenue Cycle Decoded or, on LinkedIn, Revenue Cycle for Healthcare Practice Managers and ask any questions that you might have or just join us and add your input. Also you can find me on where I have a webinar on the different sections of the revenue cycle and what can go wrong that may keep your claims from being paid in each section. That webinar is completely free, it lasts about an hour, it is on-demand so all you have to do is enter your name and email address and you will get instant access to the webinar. And I promise you, it is jam-packed with information and action tips that you can take.

I also have a course available now to help you manage and prevent your front end revenue cycle denials and you can find that also at That course right now is just $47 for a limited time and it is over 2 hours of content with action items and tools to help you be successful in managing and preventing your front end revenue cycle rejections and denials, so I invite you to come check those out.

Join me next time on Revenue Cycle for Healthcare Practice Managers Podcast or on our video YouTube channel. follow me on Facebook at Revenue Cycle Decoded. Thank you!


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