August 10th, 2015
On occasion (if not more often), every practice receives a notice of claim denial that reads, ‘duplicate service.’ When the insurance denies a service as duplicate but your records indicate that is not true, how should you act?
First, gather all pertinent information on the claim to determine a possible cause. The following are some reasons why the claim may be denied as duplicate:
- The service was billed twice but performed only once.
- The service was performed more than once by the same provider, or group of providers, on the same day.
- The service was performed by another provider, outside of your practice or group, on the same day as your service, and payment has already been made to that provider.
- The claim was submitted a second time after noticing it had still been unprocessed after 60 days. The resubmission was done to avoid any timely filing denial issues.
- The payment has already been made but not posted to the system.
- Payment for services may have been sent to the patient due to a failure to check ‘yes’ for ‘Accepts Assignment’ in box 27 on the HCFA 1500 claim form.
- The service was performed bilaterally resulting in payment for one side and denial of the other.
As you can see, there are many reasons for denying a claim as a duplicate service. Don’t be quick to write anything off at this point or to bill the patient. Research the problem and try to resolve any issues or clear up any confusion so the claim can get processed and paid.
It is important that you take the time to locate and understand the cause of the duplicate service denial and determine if the proper response should be to re-bill or appeal.
Let’s review some of the steps you can take to resolve all of the above reasons a claim may be denied as a duplicate service:
1. The service was actually billed twice but done only once.
Verify that the documentation on file matches for the service only being performed once and that payment has already been made and posted for it. If only performed once but no payment was posted, then contact the insurance company to find out if they denied the claim for another reason or if payment has already been made. If they show payment has been made, verify the date paid, the amount paid, and where it was sent to (address or electronic payment). Follow this through until the payment is received and paid and be sure to make good notes in the account for anyone else who may need to know the information you have found out.
2. The service was performed more than once by the same provider, or group of providers, on the same day.
Review the notes to determine if the same provider performed the service more than once in the same day at the same location. If so, then simply resubmitting a corrected
claim with modifier 76 appended to the CPT code may suffice.
If the duplicate service already has modifier 76 appended to it and the claim is still denied as duplicate service, the insurance may simply need an appeal letter that includes a copy of both reports for proof that they are not duplicate services.
3. The service was performed by another provider, outside of your practice or group, on the same day and already paid to that provider.
This can only be resolved by contacting the insurance company. There is no way for you to know if another provider has performed the same service elsewhere. Ask the insurance company for their policy on appealing such a denial, as each insurance has their own process for doing this. Some can fix it over the phone while others may require a full appeal letter.
4. The unpaid claim may have be more than 60 days old and unpaid, which resulted in a resubmission to avoid timely filing denial issues.
Here again, contact the insurance company and find out what the status is of the initial claim that was submitted.
As with Medicare, many insurances may have an internal policy of not processing any claims (or denying any duplicate claims) until the original claim has been fully processed.
There are many reasons the original may be taking so long to process:
- Coordination of benefits, when the patient has more than one insurance policy and they need to determine which is primary and which is secondary.
- A determination of pre-existing condition is being looked at by the insurance company in which they must review the patient’s medical records prior to processing the claim.
- The service was related to an accident or injury and determination of the type of benefits or the proper insurance carrier (auto versus medical or work compensation versus medical) must be determined.
5. The payment has already been made but not posted to the system.
This information can only be determined after contacting the insurance company. Once they tell you payment was made you will need to obtain the following information:
- Where was the payment sent?
- When was the payment sent?
- How much was the payment and does their system show it has cleared our bank?
6. Payment for services may have been sent to the patient due to a failure to check ‘yes’ for ‘Accepts Assignment’ in box 27 on the HCFA 1500 claim form.
Double check box 27 on the HCFA 1500 form and make sure ‘yes’ has been selected on the ‘accepts assignment’ question. If it is checked ‘no’ the payment will go directly to the patient and not to the provider. A patient who is on top of things may turn around and make sure the monies are paid to the provider but there are plenty of stories of patients receiving money from the insurance company when this has happened only to leave on vacation and spend it, thinking it was all for them.
7. The service was performed bilaterally resulting in payment for one side and denial of the other.
Reviewing the notes shows that the service was performed bilaterally but one of the sides was sent without modifiers 50, RT or LT. In this case, there are two ways to approach the denial. First you can simply resubmit the claim with a modifier -59 to indicate it was a separate identifiable service. If the insurance denies it again as duplicate, they may simply need to see the information. At this point, submit an appeal letter with a copy of both notes, circling the sides affected in each report for clarity.
In short, a denial for duplicate service does not mean the claim will never be paid. Do a little research and see if any of the scenarios above fit your particular situation and then act accordingly.
By Aimee Wilcox, MA, CST, CCS-P