Every practice deals with claim denials and ‘duplicate service’ is a common reason for denial. When a claim submitted by a medical coding company is denied as a duplicate service, it indicates that more than one claim was submitted for the same service, for the same patient, for the same date of service.
Blue Cross Blue Shield defines a duplicate claim as: “Any claim submitted by a physician or provider for the same service provided to a particular individual on a specified date of service that was included in a previously submitted claim”. This does not include corrected claims.
In most cases, the claim would have been already processed and paid or it is identical to a previously submitted claim. Practices need to strictly adhere to claim submission rules to avoid duplicate claims, which are not only counterproductive and costly, but can lead to scrutiny and integrity actions by the Medicare administrative contractor (MAC).
Reasons for Duplicate Claim/Service Denials
- The service was performed more than once on the same day: The same provider may provide the same service for the same patient multiple times on the same day. The first claim is likely be processed and paid, and the second claim will be denied as a duplicate claim or service. Modifier 76 Repeat procedure or service by same physician or other qualified health care professional, should be appended to the second claim to indicate that the procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. Modifier 76 is used for surgeries, x-rays and injections. If the claim is denied again, you can appeal and provide documentation.
- The same service was performed by another provider on the same date: A patient may receive a service on the same day with two different providers, A and B. If provider A submitted a claim with the same CPT code as provider B and received a payment prior to provider B’s claim, then provider B’s claim will get denied. In this case, the insurance company should be informed that provider B also performed the service and send the claim back for reprocessing. If the claim is not reprocessed, it can be appealed with supporting documentation.
- Same service was performed bilaterally by one provider: Suppose the same provider performed the same procedure on both legs of the patient and both claims were submitted without the correct modifier, one claim may be paid and the other denied as a duplicate claim. Appending modifier 50 or RT and LT modifiers would indicate the same procedure performed bilaterally.
- The service was performed once but billed twice: If the claim for a service is submitted twice, it will be denied as duplicate. This can occur inadvertently, but is a costly mistake. The payer will reimburse only the original claim and deny the second one. The practice’s medical billing service provider should ascertain whether the original claim has been processed for payment.
- Submitting a corrected claim without proper information: It is important to file a corrected claim according to the payer’s specific instructions below to ensure that payer can identify the original claim, understand the correction that is required and ensure that the resubmitted claim is not denied as a duplicate. When a claim is corrected and resubmitted, it should be clearly indicated as a corrected claim along with the original claim ID, and reason for attachments or corrections. Claims that are submitted without the necessary information will be returned or denied as duplicates.
How to Respond to Duplicate Service Denials
- If the claim for a service performed more than once on the same day is denied, verify if you submitted the claim with the appropriate modifier and other requirements. If not, rebill it with the correct modifier. On the other hand, if you submitted the claim correctly and it was still denied, submit a letter of appeal with documentation for each specific service to prove it was performed more than once and therefore is not a duplicate service.
- For a claim that was submitted twice, a Find a Code article recommends verifying the following:
- If the payment was made on the first claim, whether it was sent to the correct address?
- If the check was deposited but missed in the posting process?
- If payment was sent to the patient for failure to check the ‘accept assignment’ box on the HCFA form?
- If the first claim submitted was denied and the denial was handled correctly. Sometimes claims can be resubmitted by simply correcting a diagnosis code, modifier, or other problem.
- Denial due to ‘same service performed by another provider on the same date’ can be appealed using the method required by the insurance. Appeal methods differ among payers.
Partnering with an experienced provider of physician billing services can minimize claim denials and rejections and other billing errors. In the event that a claim is denied, they will follow up on it, and appeal claims that have not been processed correctly. Experts would also be familiar with the appeals and claim resubmission methods for each insurance company.
Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.