Every medical practice deal with claims denials, which is a notice that the claim has not been paid for specific reason. While there are many different denial codes you may see from time to time, one of the most common denial codes is the denial for a duplicate claim or service. Unfortunately, duplicate claims are both counter-productive and costly for your practice, not to mention, they can end up getting you into trouble. Too many errors can result in the imposition of program integrity actions by the Medicare administrative contractor against your practice. This means it’s essential to learn more about this common denial code, how to avoid it, and what you can do when it does happen.
Common Reasons Claims are Denied as a Duplicate Service or Claim
First, it’s important to understand why claims are denied as a duplicate claim or service. Three of the most common reasons a claim may be denied and considered a duplicate claim include:
- A service was performed once but was billed twice.
- A service was performed multiple times on the same day, which validates the denial.
- Another practitioner performed the same service on the same day and also submitted a claim using the same CPT code your practice did and it was processed before your claim was.
Helpful Solutions to Duplicate Claim or Service Denials
Depending on the reason for the denial for duplicate claim or service, you can take a variety of different actions.
Same service or claim was submitted twice but the service was performed once
When this occurs, it’s usually just an accident, but it can be a costly one. The insurance company or Medicare will only pay for one claim. What your practice needs to do is make sure that one of the claims is paid and that they don’t both end up being denied. Other things you may want to verify include:
- If payment was made, was it sent to the right address?
- Was the check from the first claim deposited?
- Was the first claim denied, and if so, was it handled correctly?
Same service was performed by another provider on the same date and was processed before your claim was
To figure out if this has happened, you’ll need to speak with someone to find out the specific reason your claim was denied. If this scenario has occurred, you’ll need to explain that your provider also performed the service and then send the claim back to be reprocessed. If they don’t agree to send the claim back for reprocessing, you can appeal this claim and provide supporting documentation.
Same service performed multiple times by the same provider
If the same procedure or service was performed multiple times on the same day and by the same provider, the claim will be denied if the claim wasn’t submitted with the correct modifier. The first claim will likely be processed and the second denied as a duplicate claim or service. If this occurs, it’s important to append your second claim with the correct modifier. If it’s denied again, you’ll need to appeal and provide documentation.
Same service was performed bilaterally by one provider and the claims were submitted without the correct modifier.
If the same service was performed on, for example, both of the patient’s hands by the same provider and both claims were submitted without the correct modifier, one claim may be paid and the other denied as a duplicate claim. To avoid this problem, or correct it if you’re facing a denial, you’ll need to bill with the correct modifier to indicate the procedure was performed bilaterally.
The claim was corrected but resubmitted without noting it’s a corrected claim
If you resubmit a corrected claim without indicating it’s a claim that’s been corrected, once again you’ll end up with a denial for duplicate claim or service. It’s always essential to indicate that a claim is a corrected claim to avoid this problem.
Talking to the Insurance Company – Know What Questions to Ask
Sometimes it may not be immediately apparent why your claim was denied as a duplicate claim or service. This means you’ll need to talk with the insurance company’s claims department to discover what the problem is. A few questions that you’ll need to ask to get to the bottom of the problem may include:
- Question #1 – When did you receive this claim?
- Question #2 – What was the date of the claim denial?
- Question #3 – Can you give me the status of the original claim?
- Question #4 – Can you provide me with the original claim number and the duplicate denial claim number?
- Question #5 – Can you please provide me with a copy of the original claim EOB?
- Question #6 – Can you provide me with a call reference number in case I need to call back to discuss this claim again?
Reporting Claims for Multiple Instances of Services or Items that are Deemed Medically Necessary
First, it’s important to know that Medicare will automatically deny claims if they have any of the following matching elements: provider number, through date of service, HIC number, procedure code, billed amount, type of service, from date of service, and place of service. Any claim lines or claims that have very closely aligned elements may be reviewed as well. If you are going to submit claims for multiple instances of a procedure, item, or service that’s medically necessary, it’s critical to include the appropriate modifier. Modifier 59 is accepted to identify different services, anatomic sites, and encounters, but new modifiers more clearly define the subsets of this modifier, including:
- XP – done by a separate practitioner
- XE – a separate encounter
- XU – an unusual non-overlapping service
- XS – a separate structure
Other modifiers that could be appropriate to help explain duplicate claims may include:
- Modifier 91 – repeat clinical diagnostic laboratory tests
- Modifier 76 – repeat procedure or service by the same provider that was subsequent to the original procedure or service
Remember, just because a claim was denied for a duplicate claim or service doesn’t mean it will never get paid. In some cases, there may be cause to resubmit the claim or appeal the denial. Always make sure to follow up on any denials so you find out the problem and see if there’s a solution that can ensure you get paid.