Is your practice filing illegal claims? Illegal duplicate claims can be costly to everyone

by Shellie Pruden DCMS director of medical practice relations

Is your practice filing illegal claims? Senate Bill 418—the Prompt Pay bill—made it illegal for medical practices to file duplicate claims. A duplicate claim is an electronic claim that is refiled before the 30-day payment deadline or a paper claim that is refiled before the 45-day insurance carrier payment deadline. At the last Texas Department of Insurance technical advisory committee meeting, the Texas Association of Health Plans discussed the prevalence of duplicate claims being filed, even though the practice is illegal. TAHP is representing the practice as fraud. Fewer than 4 percent of the commercial claims filed actually are flagged as duplicate. Although this doesn’t sound like a great volume, Aetna pays more than 200,000 claims per day. Considering the resources expended sorting out duplicate claims, health plans may have a legitimate argument.

In the Medicare Part B Newsletter No. 158 of June 1, 1998, Medicare says that duplicate claim submissions may be considered program abuse. In 1998, Medicare estimated that 6 percent of claims filed were duplicate and resulted in a $4.5 million cost to the Centers for Medicare and Medicaid Services (then HCFA) for Texas alone.

This is not just a problem in Texas. "Although CMS Believes that most providers and suppliers are not deliberately trying to receive duplicate payment by submitting duplicate claims, CMS wants to remind providers and suppliers that submitting such duplicate claims for the same service encounter is inappropriate and asks you to discontinue this practice. If you submit more than one claim for the same item or service, you can expect your duplicate claim to be denied. In addition, duplicate claims: 1) may delay payment; 2) could cause you to be identified as an abusive biller; or 3) if a pattern of duplicate billing is identified, may generate an investigation for fraud." CMS Medlearn Matters SE0415

Duplicate claims continue to be Trailblazer’s top error in processing Texas Medicare claims. Other carriers also have considered drastic measures to reduce the number of duplicate claims filed. In the recent Texas Health and Human Services bidding process for Medicaid HMO contracts, the state allows the HMO to include in its physician contracts language that releases the HMO from paying interest on claims that are not paid timely if subsequent duplicate claims have been filed.

Of course there is another side to the story. Although physician offenders do exist, physician offices report that some carriers confuse corrected claims with duplicate submissions and only during a much more expensive appeal process can the practice prove that the claims were not duplicate. Technical and process problems with crossover claims—where claims are forwarded from Medicare and Medicaid to other carriers for secondary payment—result in a marked percentage of the duplicate claims reported. In addition, contractual issues have been identified where separate claims must be filed for technical and professional components, although the insurer’s system kicks out the last of the two received, dubbing it duplicate.

To tell if your practice is filing claims to the letter of the law, ask your IT person to generate reports from your practice management system that reflect the timing of claims filing and refiling. A less comprehensive audit may be done on aged claims to see how often the claim has been resubmitted. This will give you a picture of how unpaid claims are handled. Establish or refine the practice policies on claim follow-up. Make sure clearinghouse exception reports are being worked, rather than just being refiled as claims that haven’t shown payment activity. Document in your system when follow-up on a claim reveals that the payor didn’t receive it. In addition, document when a payor requests that you resubmit a claim before the statutory time limit. Make sure this information is retrievable so that trending can be measured. By definition, a claim resent at the request of a carrier isn’t a duplicate claim. (Texas Department of Insurance Rule 21.2802, definition 11). When filing a duplicate paper claim, practices are required to place the letter “d” in box 10d to depict a duplicate claim or include the letter “c” to differentiate a corrected claim.

Physician offices that use a billing company should contact the company to make sure it has policies to not send duplicate claims. Billing companies struggle to have access to the latest legal and management information because they are removed from the communication linkage of professional associations such as DCMS, TMA, and the Texas Medical Group Management Association.

If physician practices do their part in eliminating the filing of duplicate claims, they will have eliminated an opportunity for health plans to use this as leverage to change the landmark prompt pay legislation passed last session. Bring your practice in line with current law and out from under the potential scrutiny of Medicare..