Missed appeals, bad write-offs and more from our latest audit roundup

April 5, 2019

Every week, the Vachette audit team uncovers a number of various billing and compliance issues that are preventing our clients from maximizing their revenue. Below is a roundup of a few of our major billing audit findings from the first quarter of 2019.

If any of these issues are similar to ones you or your biller are struggling with, don’t hesitate to reach out to us for a free consultation by calling 517-486-4262, or using the contact form on this page.

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  • Despite the CCI edit, 88342/88341 billed with 88360 can be approved and covered when properly appealed. We recently reviewed a case where insurance denied this as non-covered due to bundling. No appeal was performed and full balance of $180.00 was adjusted off because the biller didn’t know it was payable!
  • Having a smart policy in place for truly small balances is key to avoiding the expense of chasing miniscule amounts. For example, we recently audited a case where a patient was sent a statement for 94 cents, then was later forwarded to collections! Talk about using a hammer to kill a fly!
  • We found more than $1,000 in unbilled charges tied to a single case in our client’s billing audit. When asked why they failed to send these charges out, the biller claimed they never received an addendum for the four IHCs!
  • We had to have a tough conversation with a client’s biller after finding multiple cases in our audit that had been incorrectly adjusted off. The first was adjusted off despite simply needing to be refiled under the correct insurance, while the second was adjusted off as an exhausted appeal one day after the appeal was sent!
  • A client they lost out on $3,000 in billing because a case with a frozen section with 12 specimens was coded incorrectly. Do you have an internal process in place to periodically audit your coding process? If not, how can you know what you’re truly missing?
  • We discovered a client’s billing system was charging for 88173s at $50 below their listed fee schedule amount. That’s a nearly 30 percent loss each time the procedure was billed out!
  • A case with an 88305 was denied as a duplicate. After the first appeal was upheld, our client’s biller simply wrote off the balance instead of attempting a second-level appeal!
  • Automation is great, but if your billing system is set up incorrectly, it can lead to costly mistakes. Case in point: We determined a client’s system was incorrectly identifying modifiers on some cases, which resulted in the wrong rates being billed. In one instance, a case including global services was billed at the professional rate, costing the group $800 in the process!
  • We found a group where the biller had the small balance write-off set at $5 … per line item! Therefore, a claim with ten line items of $5 each, with a total balance of $50, would have been written off completely! Imagine how much money this group lost!
  • We’re working with a group who we discovered was coding more IHC stains than they were documenting, in part because their biller does not check the coding! We’re now working with both the group and the biller to determine how this occurred.

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Are you billing all the correct CPT codes? You’d be surprised at what you might be missing. We will review your Fee Schedule/Charge Master at no cost.

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