How Do The Potential Mistakes In Physician Billing Services Lead To Claim Denials?


It is the primary responsibility of the medical practitioners to make sure that they have sufficient resources to provide the patients with correct medical bills. So they can accurately reimburse the physicians without any hassle. Otherwise, due to the lack of well-experienced and qualified staff for physician billing services, claims get filed with a lot of electronic and human errors, and hence they are returned by the payers without getting reimbursed.

Therefore, instead of lagging behind your revenue goals, physicians should acquire the help of a professional medical billing company such as Medcare MSO. Partnering with a medical billing company would give you control over adequate resources and equipment that can reduce potential errors in your physician billing services and drive more revenue.To learn more about the physician revenue cycle services that give strengthening support to help you achieve accuracy in physician billing cycle.

However, even after outsourcing, physicians should acquire intuitive reports that can provide useful insights into physician billing services. Otherwise, if there will be a lack of proper check and balance, then practitioners might not catch the following potential errors and mistakes that can result in claim denials and rejections and ultimately revenue loss.

But before diving into the details of medical billing errors, let’s understand the difference between claim denial and claim rejection first.

Difference between Claim Rejection and Claim Denials

Errors and mistakes in medical billing services allow payers to whether to deny or reject the claims. Therefore, incorrect medical claims contribute a lot to the revenue loss of a medical business. Usually, insurance payers deal with incorrect medical claims in two of the following ways;

  • Reject Claims

The claims that contain electronic or human errors during the course of processing end up being rejected by the payer. In such cases, the medical claims are returned back to the medical billers with the explanation of errors and they are allowed to make changes and resubmit it afterward.

  • Deny Claims

When an insurance payer denies a claim that it becomes un-payable on the ground and it may violate the terms of the payer-patient contract or contain some sort of noticeable error. Medical billers are also allowed to appeal denied claims after rectifying the errors but it is the most time-consuming and costly procedure.

Therefore, medical billing specialists should make sure to avoid medical billing and coding errors at first place to get “clean claims”. Otherwise, these rejected and denied claims can pose haunting impacts on the financial aspects of any medical business. According to recent research conducted by NBC news, there is a 7 to 75% error rate in the medical billing field that causes a huge difficulty for patients and medical billers alike.

The following errors are involved in physician billing services that result in claim denials and rejections;

Simple Errors

The error could be of any size, category, or scale that may occur due to negligence during physician billing services or more serious intentional omission of fraudulent nature that can get a claim rejected.

1. Missing information

Even if the information is missing from a single field in the medical claims such as; patient’s name, gender, date of birth or insurance plan number, etc. can allow insurance payer to reject a claim. Even if the medical billers have provided incorrect details of the healthcare providers then it would also be the reason behind medical billing errors.

2. Ineligible patient for the insurance coverage

If the front desk staff has not handled prior authorization and verified the insurance number of the patient then it would lead medical billers to insert incorrect details of the health service provider, even if the patient is in-network, due to the wrong policy number, insurers would not pay for such claims.

3. Incorrect Medical codes

In addition to these errors, if a medical coder is using out-dated or wrong ICD, HCPCS or CPT codes then it could leave them out for specific procedures and diagnosis. Even if the patient has received the same service more than one time in a single day then it could also result in duplication. This duplication is a huge headache for medical billers. For example, if a patient has received X-ray two times a day, it could cause ambiguity in the medical claims as well.

Complicated Errors

Besides the common or simple medical billing errors, the following additional complicated errors can also impact the results of physician billing services negatively.

1. Under Coding

It happens when medical billers intentionally leave out a procedure code or add incorrect medical codes such as they may add procedural code for a less serious or general procedure instead of the actually received medical treatment.

2. Upcoding

It is another intentional deceptive medical coding process. Upcoding is done when the medical coders mention wrong medical services provided by the physicians instead of the actual treatment or procedure performed by the physicians to prepare costlier medical claims than the actual one.

3. Poor Documentation

Poor documentation or missing information can also potentially impact the physician billing services and disrupt the medical claim process. Erroneous, incomplete, and incorrect eligibility information contributes to poor documentation.

4. Non-provision of Explanation of Benefits (EOB)

In the case of denied claims, medical billers should also improvise the EOB statements to provide accurate information afterward to patients and payers.

5. Wrong Medical Codes For Telemedicine

If medical coders have used the wrong medical codes for telemedicine services or incorrect modifiers for telehealthcare services then they may stand responsible for payment denials.


Physicians must keep their practices safe from catastrophic medical billing and coding errors. They must keep check and balance on the information flow. Any unintentional mistake or deliberate inaccuracy can disturb the patient-payer relationship and ultimately physician-patient relationship as well. Physicians should make sure to acquire such physician billing services that are completely transparent, engaging, and free from the above-mentioned errors.

Are you looking for a reliable medical billing collection agency that can partner with you to drive positive financial results? Then acquire all-in-solution for physician billing services from the top-notch medical billing company based in the United States. Request yourself a free demo, to prevent your medical business from further claim denials and rejections and scale up your business to the new heights.

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