The following is a guest article by Ameet Sharma, CPC at Synergy Business Solutions
When unpaid claims accumulate, hiring another biller can feel like the obvious answer. Sometimes capacity really is the constraint. But before adding staff, an independent practice should ask whether the same preventable errors are generating work every month. A team can become very efficient at correcting claims while the scheduling, registration, or enrollment problem that caused them continues untouched.
The practical starting point is a monthly view of denial patterns. Much of the information already exists in the practice-management system, clearinghouse reports, and payer remittance advice. The challenge is turning those records into a short list of changes that someone owns.
Read the Reason Before Assigning the Fix
Start by separating clearinghouse or payer rejections from adjudicated denials. A claim rejected before adjudication belongs in a different work queue from a claim the payer processed and denied. Mixing them obscures where the failure happened and makes comparisons between months unreliable.
For adjudicated claims, review the adjustment reason together with the accompanying remark codes and the payer’s explanation. CMS describes claim adjustment reason codes as the overall explanation for a financial adjustment, with remark codes providing further detail. An adjustment alone does not necessarily mean a denial; contractual adjustments and patient responsibility need separate treatment.
Several codes provide useful starting points. CARC 27 relates to services after coverage ended. CARC 197 signals missing authorization or related notification. CARC 16 identifies missing information or billing errors and requires an accompanying remark code. These are examples, not a universal ranking of the most common denials. Each practice should find its own recurring patterns.
A code is also a clue rather than a complete diagnosis. An authorization may exist but have been omitted from the claim. A coverage issue may reflect the wrong payer being billed. Review a few underlying records before deciding that the solution is staff retraining or a payer appeal.
Build a Report that Leads to a Decision
Export the available claim and remittance fields for a consistent reporting period. Useful fields include payer, provider, date of service, initial submission date, adjudication date, claim identifier, denial reason, associated remarks, and current balance. Keep patient-level details inside the practice’s approved systems; an owner-facing summary generally needs counts and amounts, not patient names.
Group the results by payer and reason. Count distinct claims so repeated submissions do not inflate the apparent number of new problems. If the system records adjustments at service-line level, state whether the report measures claims or lines and use that choice consistently.
Then rank patterns by frequency and unresolved financial impact. Charged amounts are not the same as expected collectible revenue, so label dollar fields accurately. Pick one or two issues the team can investigate this month. A lengthy dashboard is less useful than a manageable change with a responsible person and a review date.
For example, if one payer repeatedly denies claims for authorization, trace the workflow from scheduling to submission. Check whether the authorization covered the service, provider, location, date range, and units, and whether the required information reached the claim. Fixing that handoff can prevent the next batch of rework.
Put Prevention Where the Work Begins
Eligibility checks should be part of the scheduling and registration workflow, with another check close to the visit when appropriate. Record what was verified and when. Eligibility information can change, and a positive check is not a guarantee of payment.
Authorization tracking should make unresolved requirements visible before services are delivered whenever possible. A shared status field or work queue in an existing system may be enough. Assign responsibility for obtaining the authorization, checking its scope, and passing it to billing. Follow the relevant payer’s requirements rather than assuming every plan handles the same service identically.
Provider enrollment deserves a place beside denial trends. Track the applicable provider, payer, service location, effective date, and unresolved enrollment tasks. Credentialing approval and active participation for billing should not be assumed to be interchangeable. When denials cluster around a new provider or location, check the payer’s records before repeatedly resubmitting claims.
Give the Physician Owner Three Clear Measures
A monthly owner review can begin with first-pass acceptance, initial denial rate by payer, and receivables older than 120 days. Define each measure before setting targets. For first-pass acceptance, track original submissions accepted without correction; keep acceptance separate from payment. For initial denial rate, use a consistent cohort of adjudicated claims and count each claim once.
Report receivables older than 120 days using a consistent aging date, with insurance and patient balances separated. Review both the amount and its share of total outstanding receivables. A changing payer mix, posting delay, or unusually large balance can affect the trend, so discuss the underlying causes rather than treating a percentage as a verdict.
End the review with an action: what changed, who owns it, and when the team will check whether the relevant denials declined. Continue working older claims while measuring whether new claims avoid the same problem.
Additional staff may still be necessary. Denial data helps distinguish a workload that needs more capacity from avoidable work that needs a process change. For a small practice, that distinction can make the next staffing or technology decision much better informed.
About Ameet Sharma
Ameet Sharma, CPC, is a CPC-certified healthcare revenue cycle professional with extensive experience in medical billing, coding, claims management, and denial resolution.
Cost Cutting. Today’s cartoon by Vaughan Tomlinson. https://t.co/TUqCdIeWbE Chop out expenses and do something cheap! Subscribe to Weekly Humorist! https://t.co/tPeOcUUhqT