5 Common Pediatric Billing Mistakes and How to Avoid Them

As pediatric healthcare providers, ensuring accurate and efficient billing practices is crucial for the sustainability of your practice. However, navigating the complexities of pediatric medical billing can be daunting, leading to common mistakes that can impact your revenue and compliance.

In this guide, we’ll discuss five common pediatric medical billing mistakes and provide actionable strategies to avoid them, empowering you to streamline your billing processes and maximize revenue.

1. Inaccurate Coding

One of the most prevalent pediatric medical billing mistakes is not coding things correctly. Maybe you always make sure that you have a -25 modifier on your well checks with vaccines, but does your team know each payer’s requirements for coding things like fluoride varnish or how they want vaccine administrations coded? Do they know how to code same-day sick-well visits for new patients? Are they able to get you paid for both an office visit and a cerumen removal on the same day? Pediatric coding errors can lead to claim denials, delayed payments, and potential audits, significantly impacting your practice’s revenue cycle.

To avoid inaccurate Coding, ensure your team is regularly reviewing coding changes, both at the national level and for each payer. Regularly audit coding practices to help identify and rectify errors before claims are submitted.

2. Failure to Verify Insurance Coverage

Another common pediatric billing mistake is the failure to verify patients’ insurance coverage before providing services. Without verifying insurance eligibility and benefits beforehand, you risk encountering claim denials and delayed payments, as well as potential patient dissatisfaction. Additionally, changes in insurance coverage or eligibility happen frequently so what was active insurance coverage last month may not be active coverage this month.

To avoid this mistake, establish a robust insurance verification process as part of your patient intake protocol. Train your staff to verify insurance coverage at each patient encounter, confirming eligibility, coverage limitations, and any required authorizations. Utilize pediatric EHR systems or pediatric software that integrates with insurance eligibility verification tools for seamless and efficient verification processes. Also, make sure your team looks closely at PCP assignments for HMO plans and, if it can’t be verified online, be sure they are calling the plan to verify coverage.

3. Inefficient Claims Submission

Efficient claims submission is essential for timely reimbursement and cash flow optimization in pediatric medical billing. When claims aren’t submitted within a day or two of the visits, this can lead to payment delays and increased administrative burden. Common issues that lead to claim submission delays include not signing off on all tasks performed in the visit, provider lags when closing charts and missing or inaccurate patient information.

To streamline claims submission, make sure your EMR is configured to capture the work you do as you order it and utilize any tools they have for helping with notes. Some systems have scribing functionality, smart texts, templates and AI tools to help with this. Also, make sure demographics are filled out correctly and accurately for each patient. Implementing a systematic review process to identify and address potential errors before claims are submitted can help improve first-pass claim acceptance rates and accelerate payment cycles. Additionally, regularly monitor claim status and follow up on any pending or denied claims promptly to resolve issues and prevent revenue loss.

4. Neglecting Documentation Requirements

Comprehensive documentation is crucial for pediatric medical billing, as it supports the services rendered and justifies reimbursement. Neglecting documentation requirements or failing to maintain accurate and complete medical records can result in claim denials, audits, and compliance issues.

To avoid documentation pitfalls, implement standardized documentation protocols that adhere to payer guidelines and regulatory requirements and set these up in your EMR so it is automatic. Provide ongoing training to healthcare providers and staff on proper documentation practices, emphasizing the importance of thorough and accurate record-keeping. Utilize templates or electronic documentation tools to streamline the documentation process and ensure consistency across patient encounters. Regular medical billing audits can help identify documentation deficiencies and areas for improvement and identify where services provided are not billed.

5. Ignoring Denials Management

Ignoring denials management is a critical pediatric medical billing mistake that can have significant financial implications for your practice. Unresolved claim denials can result in lost revenue, increased accounts receivable aging, and diminished patient satisfaction.

To effectively manage claim denials, establish a proactive denials management process that includes timely identification, analysis, and resolution of denied claims. Implement denial tracking systems to categorize and prioritize denials based on root causes, allowing you to address underlying issues systematically. Train your staff on effective denial appeal strategies and leverage technology solutions that facilitate streamlined appeals workflows. By actively managing denials and implementing corrective actions to prevent recurrence, you can optimize revenue recovery and strengthen your practice’s financial health. Follow up on every denial every time.

Get All of Your Pediatric Billing Needs Met with Altus

In conclusion, avoiding common pediatric medical billing mistakes is essential for maintaining financial viability and compliance in your practice. By addressing coding inaccuracies, verifying insurance coverage, optimizing claims submission processes, prioritizing documentation requirements, and actively managing claim denials, you can enhance revenue cycle efficiency and maximize reimbursements. Incorporating robust training, technology solutions, and proactive strategies into your pediatric medical billing practices will empower your practice to thrive in an increasingly complex healthcare landscape. Stay tuned to Altus Pediatric Billing for more insights and best practices in pediatric medical billing.

If you’re seeking reliable pediatric billing services to optimize your practice’s financial health, visit us online to learn more or set up a call with us today.