Mistake 1: Not Checking Patient Insurance Eligibility Regularly

One of the most preventable medical billing errors is failing to verify patient insurance eligibility and benefits. This should be done during every patient visit prior to rendering services. Insurance eligibility can change month-to-month, so you can’t rely on outdated information already on file. Verifying eligibility involves:

• Checking the patient’s insurance type and policy details are current
• Confirming their policy is active and not expired
• Reviewing benefit details – are there coverage exclusions or limitations? What is the deductible and has it been met?
• Looking for any changes to copays or coinsurance rates for services
• Identifying network restrictions – are you still in-network for the patient’s plan?

Failure to complete these crucial steps means you risk providing services the patient is no longer covered for. This leads to unexpected costs and confusion for the patient once they receive the bill. It also means you take on greater risk of insurance claim rejections and non-payment. Making eligibility verification part of your front desk patient intake protocols is key.

Empower your staff to utilize insurance provider websites and portals to check status in real-time. Consider integrating this process into your practice management or EHR system for added efficiency. Taking a proactive approach prevents denial of claims down the road and optimized reimbursement.

Mistake 2: Not Gathering Complete Documentation

Thorough medical documentation is the backbone of accurate billing and coding. Yet frequently gathering complete documentation falls by the wayside in busy practices. Failure to comprehensively document all services rendered during a patient visit makes proper claim submission virtually impossible. This leads to mistakes such as:

• Underbilling - Not capturing all billable services provided
• Overbilling - Billing for services not actually performed
• Misrepresenting services - Billing with the wrong CPT codes

Any of these issues can lead to claim denials or allegations of fraud. So what constitutes complete medical documentation? For each date of service your documentation should include:

• Patient intake forms - Details current symptoms/conditions
• Medical history - Ongoing conditions, medications, etc.
• Chief complaint - Purpose for visit
• Physical exam notes - Findings during clinical evaluation
• Review of systems - Body systems reviewed and status
• Lab/test orders - Any diagnostic tests ordered
• Clinical assessments - Official diagnoses made
• Treatment plans - Services provided, prescriptions, etc.
• Discharge instructions - Follow up care instructions

This information paints the full picture of the patient encounter. Ensure your EHR or paper charting templates facilitate robust documentation. Train clinical staff on completeness. Perform periodic documentation audits to verify all elements are captured consistently. Accurate codes and proper reimbursement hinge on complete medical charting.

Mistake 3: Relying On Inaccurate Coding

Medical billing and coding is a specialized skill—one that requires certified coders with the expertise to translate clinical documentation into accurate procedure and diagnosis codes. Many practices unfortunately leave coding responsibilities in the hands of clinical or administrative staff who lack proper training. Coding is far more complex than looking up a code in a cheat sheet and picking one that seems close. Inaccuracies such as:

• Picking codes for more basic services vs. what was truly performed
• Choosing codes for similar but incorrect diagnoses
• Selecting codes already denied for a particular payer
• Billing with outdated codes no longer in use

All lead to higher denial rates and lost revenue. Practices must make the investment in certified professional coders—either by training existing staff or outsourcing coding needs. Certified coders know how to:

• Identify the highest levels of E/M service codes supported by documentation
• Code to the specificity documented in the medical record
• Follow proper guidelines for coding primary, secondary, tertiary diagnoses
• Update coding knowledge as guidelines change
• Query physicians when documentation lacks clarity
• Ensure codes are valid and billable

Proper coding helps optimize reimbursement and avoid audit risk. Submit clean claims the first time. Make coder education and continuing training a priority. Conduct coding audits to validate accuracy. And leverage technologies like encoders to aid coders in staying up-to-date. Don’t underestimate the revenue implications of inaccurate medical coding.

Mistake 4: Not Tracking Pending Claims

With the fast pace and volume of medical billing, it’s easy for pending claims to fall through the cracks. Lack of follow up on open claims is revenue leakage waiting to happen. Beyond initial claim submission, dedicated tracking processes are essential for resolution.

First, proper claim tracking involves logging and dating all claims upon submission. Designate staff members accountable for monitoring claim statuses. Set reminders to follow up at 30, 60, and 90 days on unpaid claims. This helps surface any pending issues so they can be addressed in a timely manner.

Second, train staff on proper claim follow up protocols, including:

• Identifying denial reasons - Was more information requested? Is it a coding issue?
• Resubmitting denied claims with proper corrections
• Appealing denied claims when appropriate
• Sending requests for additional information
• Following up on pending claims with phone calls
• Logging all activities in each claim’s record

Organized tracking improves management of pending claims. It enables staff to stay on top of next steps for resolution. Leverage your practice management software reporting capabilities. Generate open claim reports to easily view statuses. Design workflows to handle follow-ups within set timeframes. Don’t allow claims to languish—the longer they stay pending, the less likely you are to receive payment.

Lastly, analyze pending claim patterns to reveal areas needing improvement—like procedures prone to denial or coding inaccuracies. Tighten up processes accordingly. Consistent tracking and timely follow up is key to claim completion.

Mistake 5: Not Pre-validating Claims

Clean claim submission starts before you hit “send”—with comprehensive claims pre-validation protocols. Pre-validation helps identify issues in coding, coverage, or documentation before reaching the payer. This prevents rejections upfront and eliminates wasted rework down the road.

Invest in tools that facilitate automated pre-validation and catch a high percentage of errors. Common pre-validation checks include:

• Missing or invalid patient policy number
• Wrong dates of service
• Non-billable or outdated codes
• Incorrect modifiers
• Diagnosis/procedure code mismatches
• Required documentation absent
• Services outside policy coverage

Tools can run claims against pre-validation rules specific to each payer. This flags common mistakes proactively so staff can correct them before submission. It reduces denial rates and prevents revenue leakage.

Pre-validation tools also improve staff productivity. Billing teams waste significant time on manual reviews. Automating double checks of claims frees staff to focus on value-added resolution and follow up.

Make sure to track and analyze frequent pre-validation failures. Identify if additional staff training is needed in certain areas. Keep coders informed of common coding errors so they can prevent them upfront. Tweak processes that result in faulty claims. Think of pre-validation as “claims QA”—an opportunity to improve quality before it reaches payers. Don’t leave money on the table due to avoidable submission errors that pre-validation can catch.

Mistake 6: Not Standardizing Billing Workflows

Unclear processes, inconsistent protocols, and lack of accountability all undermine efficient billing operations. Without standardized systems and workflows, staff lacks direction. Issues fall through the cracks. Delays occur when no one knows the next step.

Creating standardized workflows involves:

• Documenting billing protocols in writing
• Clearly defining each team member’s responsibilities
• Establishing timeframes for completing billing tasks
• Identifying hand-offs between departments/staff
• Communicating workflows through training
• Displaying quick-reference workflow guides

Standard processes create consistency and efficiency. All staff understand expectations and hand-offs. Use checklists and protocols to guide staff through key areas like claims development, submission, tracking, denial resolution, and reporting.

Leverage technology to systematize workflows when possible through task notifications, status dashboards, and automated hand-offs between billing steps.

Make sure to continually monitor and refine standardized processes. Identify bottlenecks causing slowdowns. Evaluate redundant or unnecessary steps. Streamline workflows to maximize productivity. Update protocols as new payers, regulations, or systems are implemented.

Standardized billing workflows enable staff to work collaboratively and efficiently. They limit potential for costly errors and oversights. Don’t rely on ad hoc processes. Documented, systematized protocols form the foundation of smooth and accurate billing operations.

Mistake 7: Not Training/updating Staff Regularly

Medical billing and coding skills require continual learning. Rules, guidelines, and payer requirements change frequently. Staff that doesn’t receive regular training quickly develop knowledge gaps. This contributes to denied claims and subpar revenue.

Make formal billing, coding, and compliance training central to your practice. Require staff to obtain a minimum number of continuing education credits annually from certified programs. Strengthen competencies in areas like:

• CPT, HCPCS, and ICD-10 code updates
• Coding for medical necessity
• Modifier usage
• E/M service coding
• Claim form completion
• Payer-specific requirements
• Compliance and auditing protocols
• Changing regulations and laws

Formalize onboarding programs for new hires—don’t just throw them into the work. Partner inexperienced coders with senior coders for mentoring. Maintain an onsite reference library of coding manuals, bulletins, and guidebooks. Have coders take annual proficiency assessments.

In addition to external learning, create internal training programs. Give regular refresher sessions on processes and top claim denial reasons. Share new payer rules and trends with the team. Make training fun with billing competitions or jeopardy-style games.

Investing in education improves staff capabilities, morale, and efficiency. It ensures their hard-earned knowledge doesn’t become stale or obsolete. Prioritize developing billing and coding experts within your practice. It pays dividends in cleaner claims, fewer denials, and maximized revenue.

Mistake 8: Not Auditing Regularly

Auditing your billing and coding work is essential for catching errors before they turn into claim denials or compliance issues. Yet few practices make auditing central to their quality control process. That’s a missed opportunity for huge returns.

Build internal audits into billing workflows on an ongoing basis. Audit a percentage of all claims to check accuracy in areas like:

• Coding - Were the right CPT/HCPCS codes used?
• Billing completeness - Were all billable items captured?
• Modifiers - Were modifiers applied correctly?
• Medical necessity - Does documentation support the codes?
• Payer guidelines - Do codes adhere to payer rules?

Use predetermined audit protocols and scorecards to ensure consistency. Provide the data and feedback to coders and billers so they can continuously improve. Their insights into frequent errors found during audits is invaluable for strengthening processes.

In addition to internal audits, consider external audits periodically by expert consultants. They provide unbiased assessment of compliance risks and opportunities for better documentation, coding, or billing practices.

Leverage auditing tools to automate and streamline the process as well. Products can flag common coding mistakes or compliance red flags for easy identification.

Don’t view auditing as punitive. Position it as quality assurance measures to elevate billing accuracy. The more you audit, the quicker staff will resolve pain points and improve efficiencies. Auditing leads to cleaner claims, fewer denials, and maximized reimbursement. Make it a cornerstone of your billing program.

Mistake 9: Poor Denial Management Practices

Denials are a fact of life in medical billing. How you manage them however makes all the difference in revenue outcomes. Without an organized denial management process, you have little hope of reversing denials and recouping reimbursement.

To improve denial management:

• Create a system to record, track, and report on denials
• Categorize denial reasons (e.g. coding, eligibility, bundling)
• Set benchmarks for denial rates by payer/reason
• Train staff on protocols for resolving common denial types
• Establish metrics for denial overturn rates
• Conduct root cause analysis on pervasive denial patterns

Resolve denial disputes through payer calls and written appeals. Gather supporting documentation and take a collaborative tone. Structure appeals to clearly address denial reasons and site contractual provisions or laws supporting your position.

Identify top denial sources such as coding inconsistencies or missing signatures. Tackle root causes through added training, audits, or revised protocols. This improves processes to avoid similar denials moving forward.

Leverage denial management technology to auto-code denials and streamline resolution workflows. Automated tracking provides insight into performance benchmarks.

View denials management as a component of continual revenue cycle improvement. Apply lessons learned through denials to tighten up documentation, coding, billing, and other protocols that impact reimbursement. Effective denial management quickly recoups lost revenue.

Mistake 10: Not Staying Up-to-date On Changing Rules

Medical billing doesn’t stand still—from changing payer plan details to evolving coding guidelines, staff must stay vigilant. Falling behind on new requirements leads to avoidable claim denials and compliance risks.

Make ongoing education and monitoring of billing rules a top priority including:

• Have coders regularly review code change bulletins and erratas
• Monitor payer websites/portals for policy and procedure changes
• Review clinical documentation for new cost-cutting measures like downcoding
• Scan industry publications for coverage and reimbursement trends
• Stay on top of local Medicare contractor policy updates
• Maintain compliance with HIPAA, Stark Law, Anti-Kickback statutes

Sign up for email alerts from key payers and industry groups to stay current on changes. Attend webinars or conferences to learn of new regulations and best practices. Follow leading billing/coding blogs and discussion groups.

Incorporate key requirements into staff training and desk references. Update billing systems and workflows to accommodate new mandates before they take effect. Don’t allow your practice to operate in the past—proactively adapting to evolving billing rules is the only way to avoid a rash of denials and compliance exposure. Making continuing education and monitoring a priority allows your billing operation to stay current and thrive through ongoing change.

Conclusion

Preventing common medical billing errors takes diligence across clinical and administrative functions. From proper coding to denial management, seemingly small billing mistakes translate into lost revenue and profitability if left unchecked. Use this guide to assess your own practice’s vulnerabilities when it comes to the ten pitfalls outlined. Just avoiding one or two can significantly improve your efficiency and cash flow.

Implement layered processes that promote accuracy. Leverage technology like encoders and auditing tools to systematize quality control and compliance. Make staff training an ongoing priority, not just a one-time event. Set and monitor benchmark metrics around denial rates, first-pass acceptance, and days in A/R. Apply lessons learned from claim rejections to continuously elevate performance.

Medical billing mastery doesn’t happen by accident—it requires purposeful effort to implement systems that catch errors proactively while also enhancing staff capabilities over time. Use this guide as a roadmap to instill excellence into your billing and revenue cycle management. Avoiding these 10 common mistakes allows your practice to be reimbursed promptly and properly for the quality care you provide.