When Resubmitting Claims Can Get You in Trouble
What do you do when an error on a claim is discovered by someone in your practice after the claim has been processed?
According to National Government Services (NGS), many physician practices correct such claims and then resubmit them. The problem with doing this is that these claims have already been finalized – thus, these resubmitted claims become duplicates — potentially exposing your practice to Medicare fraud accusations.
Generally, adjudicated claims you believe to be inaccurate must be appealed, and should not be resubmitted, the Part B Medicare administrative contractor (B-MAC) explains in a September 9 news article on its website.
When you discover a mistake on an adjudicated claim, your first clue as to what to do is to read the remark code on the adjudicated claim:
MA01: A claim that has been finalized will contain the remark code MA01, indicating you may appeal the decision if you do not agree with it.
MA130: This code will display on the remittance advice if your claim is being rejected for incomplete or invalid information. You cannot appeal these claims.
Remark code MA130 does not mean you have no recourse. And sometimes, even if it’s permissible, appealing might be overkill for the wrong you want to right. If you need to correct a previously adjudicated claim, you may be able to simply submit a reopening request.
Requesting a reopening is appropriate when you want to correct a minor clerical error or omission. The Centers for Medicare & Medicaid Services defines clerical errors as human or mechanical errors, such as:
- Mathematical or computational mistakes
- Transposed procedure or diagnostic codes
- Inaccurate data entry
- Misapplication of a fee schedule
- Computer error
- Denial of claims as duplicates, which are denied as a result of a clerical error or minor omission and require a change on the face of the claim (in order for the claim to be reopened.
(Exception: NGS will reopen claims that denied as a duplicate when multiple services have been billed and some are denied due to a separate claim submission. For example, when three radiology services have been paid on one claim and a fourth one denied as a duplicate due to a separate claim submission and a request is made to allow a total of four services.)
- Incorrect data items, such as provider number, use of a modifier, or date of service
You can request a reopening for minor errors such as these by contacting your MAC via telephone, in writing, or your MAC’s proprietary system, such as NGS’s NGSConnex. Generally, you have one year from the remittance advice date to request a reopening. You may be able to request a reopening beyond that deadline, but you’ll need to do it in writing, and you must include documentation that supports the reason for your delayed request.