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How to Avoid Healthcare Overpayments: Top Five Mistakes Providers Make and the Real Cost of Non-Compliance

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Over the last 25 years, I have assisted healthcare providers as a lawyer and as a compliance professional with handling routine overpayment matters, internal and external billing investigations, and fraud and abuse matters. Except for the rare case involving intentional overbilling or fraud, I have found that the overpayment matters are usually caused by one big mistake: not understanding the payor’s requirements for billing and not investigating whether other providers in the group or organization understand the payor’s requirements.

It seems like a simple task: Understand what the payor requires in order to receive reimbursement from that payor for your services. But, in practice, providers often don’t study the payor’s requirements or don’t investigate whether their providers are billing compliantly. This article is intended to point out the top five mistakes I have observed through the years related to claims submissions and the real cost when the mistakes happen.

Mistake One: Not Studying Payor Requirements Before Submitting Claims

For some reason, it is quite common for a provider to get a contract with a payor and immediately start submitting claims with only a vague idea of what the payor actually requires in order for the provider to be reimbursed for […]

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