Duplicate Claims

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Estimated Duplicate Claims for the Year adobe portable format document

Approximately six percent of all claims filed to Medicare Part B are denied as duplicate claims.  Duplicate claims cost the Medicare program millions of dollars annually and are an unnecessary waste of federal funds.  Medicare carriers spend additional time, effort and money when duplicate claims increase the number of claims and appeals.  Duplicate submissions cost providers money by increasing staff time and effort as well as practice expenses if, for example, a billing service charges per claim submission.

Although duplicate claim submissions will occur from time to time, Medicare expects the rate of occurrence to be less than one percent of all claims processed.  Patterns of filing duplicate claims are considered a form of program abuse.  According to the Centers for Medicare and Medicaid Services (CMS), abuse is defined as:

"Intentionally or unintentionally filing duplicate claims to the Medicare program, even if it does not result in duplicate payment.  Abuse may, directly or indirectly, result in unnecessary costs to the Medicare/Medicaid program."

Medicare works with providers to eliminate duplicate claims whenever possible.  However, Medicare may remove providers from the electronic billing network if they continue to submit duplicate claims.

Avoiding Duplicate Claim Submissions

Q1. How can I identify claim submission dates to find a duplicate claim?
A1. Medicare claims are assigned Internal Control Numbers (ICNs) to identify how and when Medicare received the claim.  The ICN appears on the Provider Remittance Notice (PRN).

In Wisconsin, Illinois, Michigan, and Minnesota:

The first seven numbers indicate the region (whether the claim was an electronic or paper claim), the year the claim was submitted, and the date Medicare received the claim (Julian date).

A PRN with an ICN of 2202225056020 is read as follows:

  • Positions 1-2 indicate the region. Electronic claims are assigned region codes 02 for Illinois, 11 for Michigan, 22 for Wisconsin, and 32 for Minnesota.   The first two positions of the above ICN are "22," so the claim was submitted electronically in Wisconsin.
  • Positions 3-4 indicate the year the claim was submitted. The positions are "02," meaning the claim was submitted in 2002.
  • Positions 5-7 indicate the date the claim was received (by Julian date).  The Julian date is defined as "the sequential day count of the days of a year, reckoned consecutively from the first day of January."  This claim was received on day 225 of 2002, or August 13, 2002.

The last six positions represent internal batch and sequence numbers assigned to the claims submitted on that day.

With this information, providers may refer back to the confirmation/acknowledgment and/or claim submission summaries to determine the source of the duplicate problem.
 
Q2. How long should I wait before I re-file my claims when I haven't heard from Medicare?
A2. Before re-filing a claim, allow sufficient time for the claim to reach Medicare, for Medicare to process the claim, and for the Provider Remittance Notice to reach you.  If you do not submit claims electronically or receive your remittance notice electronically, you must allow time for mail processing and delivery.  Claim processing time cannot be shorter than the "payment floor," which is 14 days for electronic claims and 27 days for paper claims.  This is the minimum amount of time that must elapse from the date Medicare receives the claim until the date Medicare issues a payment.  Actual processing time can take longer.  Also, before re-filing, always carefully review your PRN to reconcile your records, or access the Interactive Voice Response (IVR) system for claim status, or contact the Provider Inquiry Line for the status of specific claims if you are unable to determine status from your PRNs or the IVR.

Do not automatically re-file claims to Medicare Part B without first obtaining the status of the original claim.  If your software automatically re-files claims, please disable this software capability, or reset your system to wait a sufficient amount of time after the claims have reached the payment floor.  It is not appropriate to use an automatic re-filing system as an alternative to bookkeeping.

You can avoid duplicate claims by tracking claims submitted and processed.  Also, when submitting claims, send either a paper or electronic claim.  Do not submit the same claim both ways.
 
Q.3 What if I have software problems?
A3. If you determine that your computer system is inadvertently resubmitting claims without your knowledge, stop transmitting claims and contact your electronic claims submission software support vendor immediately.
 
Q.4 What are some other things I can do to help me avoid duplicate denials?
A4. The following reporting suggestions will help providers to receive the maximum Medicare Part B benefits when the claim is initially processed while avoiding duplicate denials.
  • When a diagnostic procedure is performed during separate patient encounters (e.g., different times of the day), the second diagnostic procedure should be reported with procedure code modifier 76 (repeat procedure by the same provider).  Although valid, this modifier does not document payable services during the global period.  (This modifier is not valid with surgical procedure codes.  Repeat procedures for treatment of complications should be billed with 78 modifier.)
  • When two distinct and separate diagnostic procedures are rendered by two different providers (e.g., one of the procedures was not a re-reading), the provider who rendered the second procedure should report procedure code modifier 77 (repeat procedure by another provider).
  • When performing a procedure that could be performed bilaterally, please be sure to indicate the appropriate modifier(s), e.g., RT (Right side; identifies procedures performed on the right side of the body), LT (Left side; identifies procedures performed on the left side of the body), or 50 (Bilateral procedure).
  • If a claim is being resubmitted to obtain payment for denied charges, resubmit only the denied charges (e.g., a claim was submitted for procedure codes 93010, 94010, 71010, and 93922.  Medicare paid all of the procedures except 71010.  When you resubmit your claim, only refile procedure 71010).

Page Last Updated: Monday, 09-Jun-2008 15:27:03 CDT