The Role of Medical Coding in Preventing Claim Billing Errors that lead To Medical Appeals

Medical coding, the action of writing down what the doctor or surgeon says and does, plays a large role in medical billing. If the coder is not accurate, then the bills, or claims, will be incorrect, leading to unpaid claims that end up as medical appeals. Thankfully, there are some things that you can do in order to ensure that your coders follow procedure, lest you end up with a number of claims that need to be collected through the Federal ERISA process. Here’s what you need to know.

It All Starts With Documentation

Essentially, according to the experts, “Medical coding professionals take information from the medical record documentation and assign appropriate diagnoses and procedure codes, according to AAPC. They then develop an insurance claim, which indicates how much the insurer owes for the care and helps determine how much the patient will be billed.” This is a neat summary of the process, just in case you weren’t aware of how it works. Billing and coding do indeed go hand in hand – and that documentation is crucial.

You really do need to understand the difference between medical coders and medical billing. The leading organization for medical coders points out that “medical coders are not the same as medical billers. Medical coders use classification systems to assign codes, including the International Statistical Classification of Diseases and Related Health Problems. Medical coders may also audit and re-file appeals of insurance claim denials. Medical billers process and follow up on claims.” However, the two jobs do need to work in tandem when it comes to reducing coding errors.

According to recent statistics, “In 2018, the most common medical coding errors identified by the American Medical Association were unbundling codes or using multiple current procedural terminology codes for parts of a procedure, and upcoding.” Any errors within the medical codes lead to incorrect claims. The commercial insurance companies obviously won’t pay any of these incorrect claims. They’ll need to be corrected before this happens, which take up even more time. Meanwhile, the hospital’s bills still need to be paid.

Plus, correctly those claims doesn’t necessarily mean that they’ll be paid. The commercial health insurance company may skip over them, causing them to go through the medical appeals process, which can be quite lengthy and time-consuming.

The Medical Appeals Process Comes Next

The medical appeals process itself causes some complications. When those claims come back unpaid or underpaid, the billing employees need to look up the contract terms that they fall under. If it were just one or two of these claims per day, that wouldn’t be a big deal. It wouldn’t take much time to look them up. However, some hospitals are getting hundreds of these rejected claims sent back per day. On top of this, there are numerous different contracts to look up. Some depend on the particular doctor or procedure. Others cover entire departments. Now imagine those three circumstances and multiply them by the number of commercial insurance companies that operate in a certain geographic area. As you can imagine, this causes quite a situation, especially when the claims process changes regularly.

When the unpaid or underpaid claims are sent back to the clinic or hospital, they can only be appealed three times at the state level. There may be times when a portion of the claim is paid; then it’s appealed, only to have it rejected. On the third try, another portion of it may be paid. The end result is an underpaid claim, which ends up getting placed in the bad debt column of the financial ledger. All of this started with incorrect medical coding, which led to claims that were not billed correctly. This is proof of just how important the coding position is. Those who do this job must have a vast understanding of medical terminology and other information.

There’s Still Hope After Those State-Level Appeals Are Finalized

Medical appeals can wreak havoc on your bottom line. Hospitals and clinics have a lot of bills to cover. They need to pay their employees, cover the costs of new and improved equipment, and make sure that the utilities stay on. They also need to keep their buildings (and parking lots) clean, ensure that they have all of the necessary supplies, and even put new (non-billing) processes into place, such as those that connect all of each patient’s records from various departments. It’s not good to have millions of dollars sitting in a debt bucket. This is what leads many hospitals to go bankrupt. They end up with too many unpaid medical appeals and not enough cash flow. They need to find a way to collect on those unpaid and underpaid claims.

The main issue is that many of the people in charge of these hospitals don’t realize that there’s a better solution. They don’t teach people about the Federal ERISA process in law school or even in your typical medical billing course. Because of this, the process flies under the radar. Many clinics don’t realize that they have this option until it’s too late to do anything about it. They start the bankruptcy or restructuring process, only to find that had they filed Federal ERISA claims months beforehand, they’d be in much better shape today.

What The Federal ERISA Law Does

There’s a useful solution to those rejected medical appeals – the unpaid and underpaid claims that are sitting in your clinic or hospital’s debt pile. It’s called the Federal ERISA process. ERISA is short for Employee Retirement Security Income Act. This federal statute covers several different things, including commercial health insurance companies that offer self-funded employee plans. According to the law, those companies must pay the claims from those medical appeals. The main issue is that many people, especially the ones employed in your billing department, don’t know how to file the necessary paperwork to get them to pay up. Even if they did, those same employees are so busy balancing the state-level appeals and current claims that they don’t have the time. Thankfully, there’s an option – a company like us, ERISA Recovery. We train our employees on every aspect of the Federal ERISA process. As a result, we can get that money for you. We even have a guarantee in place. We can recover one million dollars of those claims for you in a 12-month span, as long as we receive all of the right paperwork from you.

We Can Help You

If you have medical appeals that have piled up and are sitting on the wrong side of your balance sheet, you need to call in the experts at ERISA Recovery. Our employees understand the Federal ERISA process and can clear up those old unpaid and underpaid claims. On top of that, we don’t charge anything upfront for our service. If you’re ready to see what we can do to help your hospital or clinic, thanks to the Federal ERISA process, give us a call at (972) 331-4140 or fill out the contact form on our website. Once we receive your information, one of our experts will give you a call.