Surprisingly, a great number of providers file “duplicate” TRICARE claims each month. Thousands of duplicate claims are
identified each quarter of the year and many are reviewed for potential fraud.
 

Why does this occur?  

There are several scenarios that lead to duplicate claims submissions, if not closely monitored. Here are some things to remember to help you avoid the costly mistake of submitting duplicate claims:
 

• The higher your claims volume, the more likely duplicates are to occur.
• Duplicate claim submissions tend to happen more often with professional claims than with institutional ones.
• Following laboratory and radiology claims, mid-size provider offices and groups tend to submit the largest
  number of duplicates.
• Duplicates appear in both electronic files and paper submissions.
• Many providers’ offices re-file without allowing time for the first claim to be adequately processed.

Why are duplicates a problem for the provider?  

At face value, a duplicate claim may not appear to be a major issue. However, if the claim is being filed
electronically, it may overlap with the previously submitted claim and cause a delay in processing. In addition, paper
duplicates may be entered before the original, making it more difficult to track the claims. Furthermore, there
may be times when you intend to file a “corrected claim;” however, if the claim is not flagged as a “corrected
claim,” it will be denied as a duplicate.
 

Duplicate claims submissions can also be a bookkeeper’s nightmare. If your office’s patient accounting system were to track the duplicate as a separate claim, it could mistakenly duplicate the patient’s copayments and expected reimbursement. Duplicate claims should also be a reason for concern if your office uses a billing service or a clearinghouse to file its
claims—particularly if you are being charged per claim!
 

As the claims processor for TRICARE in the South Region, PGBA must assign an internal claim number to every incoming claim, whether electronically or on paper. This can make it very difficult for PGBA to discern which claim is correct,
especially if it has been submitted several times in the same month.
 

  
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Created: August 6, 2007