Diagnosing Duplicate Billing for Healthcare Claims: A Complete Guide


An Introduction to Duplicate Billing Denials

When working with our clients, we always ask, “What are some of the most common denials you see?” If duplicate billing, represented by claim adjustment reason code 18, lands within their top five, they have a serious problem. After twenty years in the industry, we’ve consolidated a complete guide to avoiding these types of denials.

The duplicate billing denial code is almost always as a result of human error due to…

  • Billing for the same patient procedure, treatment, or testing on more than one occasion

  • Billing for the wrong patient service

  • Billing for patient services that were never performed in the first place

  • Attempting to bill Medicare or Medicaid and either another private insurance company or the patient directly

  • Charging more than once for the same service

  • Not checking if a procedure has already been billed

Duplicate billing for healthcare claims can sometimes be viewed as fraud. As a result, there are many instances where healthcare organizations of all sizes have to pay fines.

Duplicate Billing Categories

Healthcare insurance’s claims processing systems have defined criteria to evaluate all of the claims they receive to determine potential duplication. Once they process a claim that is potentially a duplicate billing it is placed into one of two categories…

  • Exact duplicate

  • Suspect duplicate

From there, there are certain criteria within the exact duplicate claims that are scrutinized…

  • Procedure code

  • Provider number

  • Through date of service

  • Type of service

  • Billed amount

  • HIC number

  • From date of service

  • Place of service

The Cost of Duplicate Billing

If your organization commits any of the listed practices within the introduction section above, you can expect duplicate claim denials. Duplicate billing denials cause…

  1. Delay and/or loss in payment

  2. Potentially cause your organization to be identified as an abusive biller

  3. If a pattern of duplicate billing exists, it may generate fraud investigation

According to Health Payer Intelligence, 46% of medical fraud cases were due to fraudulent provider billing, duplicate billing, and billing for services not medically needed. These fraudulent cases cost a total of $29 million in fines.

Remedies to Avoid Duplicate Billing Denials

Avoiding these types of denials requires diligence and clear communication between your entire staff. The remedies to avoid duplicate billing denials are similar to timely filing limit denials due to the fact that they are directly related to healthcare insurance companies.

  1. Conduct Chart Audits

    One of the best ways to prevent these type of denials and fraud investigations is to perform chart audits. Chart audits are a simple, yet highly effective way to ensure all parts of a healthcare claim are billed correctly.

    Conducting chart audits has many additional benefits by helping you; measure the quality of care, streamlining internal processes, review physician performance.

  2. Educate Staff

    Another way to avoid these types of denials is to refrain from submitting multiple claims for the same item or service. To do this, educate your medical billing staff or third party billing service knows some of the most common healthcare insurance’s claim filing rules.

  3. Establish a Front-End System of Checks and Balances

    Duplicate billing denials need to be addressed before they happen. This requires that you set up a system of checks and balances throughout your entire healthcare organization. Below are a couple of simple ways to establish a system of checks and balances to avoid duplicate billing denials and practices…

    • One person or group of people is responsible for monitoring electronic billing information prior to processing

    • There is a solid communication link between the individual and/or team who render services and those who submit statements to insurers and payers

    • There are 30 days from the claim receipt date for the claim to process before resubmission of a subsequent claim for the same service(s)

    • Remittance Advice is checked for a previously processed claim before submitting a new one

    • If the initial claim did not allow payment, a verification reason is determined

    • Change billing system options to not bill secondary claims until primaries are posted