Is it mandatory for all services to be billed?


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Just a curious question.

If a physician reads radiology xrays, EKGs, etc and the biller missed billing the professional component (due to paper shuffle, some may be missed), is that "illegal"?

A biller at our office says that it will harm the patient and it will cause trouble for the practice?

She also says that if insurances didn't get the code the xray to specificity the patient might get future services denied by insurances? (E.g. arthritic degeneration of knee if not coded, may get denied for knee replacement surgery)

I'm not understanding why insurances would base on codes and not the physician's notes. Most of these procedures require pre auth.

Thanks for clarifying.


True Blue
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I think your biller is over-reacting a bit. First of all, mistakes are not 'illegal' - everyone makes errors - but it is a best practice to correct them when identified. The main legal concern about incorrect billing is when it is intentional, negligent and/or a systematic misrepresentation of services. It could be problematic or raise questions if your practice did this repeatedly, but not if it is an isolated case. Second, I think it is highly unlikely that failing to bill a professional component would cause any harm to the patient or practice. For all practical purposes, payers are really only concerned about provider billing errors when it costs them money by causing an overpayment. And while there may be rare cases where a future claim might deny if a prior service had not been billed, such situations can be rectified through appeals or by making the necessary corrections to prior claims.

I think you are correct that, ultimately, decisions will be made based on physician notes. I have never known payers to make any patient-specific authorization or benefit determinations based solely on a patient's claims data. Payers do use claims data for informational purposes, but medical records, plan documents and provider contracts are the final source of truth for determining whether or not to pay for a service.
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