Thousands of duplicate TRICARE claims are identified each quarter of the year, many of which are reviewed for potential fraud. However, most providers are unaware they are generating duplicate claims.
 
Here are a few reasons why and where duplicate claims may appear:

• A claim is refiled without allowing time for the original submission to process.
• A corrected claim is filed improperly, is then processed as a duplicate claim and is therefore denied. This sometimes happens repeatedly for the same episode of care.
• Providers with a higher claims volume are more likely to submit duplicates.
• Duplicate claim submissions tend to occur more often with professional claims than institutional claims.
• Aside from laboratory and radiology submissions, mid-size provider offices/groups submit the bulk of duplicate claims.
• Duplicate claims occur with both electronic and paper submissions.

If a duplicate claim is submitted electronically, it may overlap with the originally submitted claim and cause a delay in processing. Duplicate paper claims can also overlap since they cannot be tracked until they are entered into the claims system. The duplicate claim may be entered into the system before the original and then become difficult to track. In addition, if a corrected claim is not flagged as a corrected claim, it will be denied as a duplicate.
 
Duplicate claim submissions can be a bookkeeper’s nightmare if your office’s patient accounting system tracks the duplicate as a separate claim, anticipating duplicate copayment and reimbursement.
If a billing service or a clearinghouse files your claims, are you being charged per claim? Billing services and clearinghouses may not be allowing enough time for your claims to process, or they may be ignoring the response on the remittance asking for more information or to update the claim before refiling it as a corrected claim.
 
As the claims processor for the TRICARE South Region, PGBA, LLC (PGBA) must assign an internal claim number to every electronic and paper claim it receives. Tracking a claim becomes very difficult when a provider’s office contacts PGBA to ask about a claim that has been submitted two or more times within a month.
 
Possible solutions to the duplicate claims process include filing claims electronically, providing a reasonable period of time between claim cycles and ensuring timely resolution of the claim payment/response. By adding electronic remittance advice and electronic funds transfer to your claims interface with PGBA, you should be able to post responses and funds to claims more rapidly and accurately. Providers who move to total electronic claims transactions appear to have fewer issues with tracking claims and producing duplicates.
 
Remember, a duplicate claim is not recognized as a corrected claim unless it is flagged as such. Responses from your remittance should tell you what has happened to the claim and suggest next steps if the claim did not result in payment. Many provider offices resubmit the claim as is; however, the claim will be rejected as a duplicate submission unless it is resubmitted as a corrected claim.
 
Providers who use PGBA’s Web site, myTRICARE, can view previous remittances, check the status of claims and inquire about a claim response without introducing a duplicate submission.

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