Welcome to Edition 3!
Every new client relationship starts the same way for us: we open up the revenue cycle and run the audit. Different specialties, different sizes, different software. And the findings rhyme. Almost nothing we discover arrives as a crisis. It's underperformance, accumulating a little at a time, in places nobody was assigned to look.
This edition is the pattern report. The three findings that keep coming back, and what each one means for you.
THE FIELD
The three findings that keep coming back, across every specialty we serve.
Finding one: claims parked at “submitted.”
The most common finding by a wide margin. Claims went out the door, the system marked them submitted, and the follow-up stopped there. Payers pend things, request information, or simply sit, and nothing alerts anyone while filing and appeal clocks run in the background. What it means for you: at your next billing conversation, ask one question. Of everything marked submitted for more than 45 days, who owns the chase, claim by claim? A specific answer is a good sign. A general one is the finding.
Finding two: denials born at check-in.
When we sort a new client's denials by reason, the top of the list usually points upstream: coverage that lapsed before the visit, registration details keyed wrong, authorizations obtained but never attached. The back office wears the blame for problems manufactured at the front desk, and the front desk never finds out.
What it means for you: pull last month's top denial reason. If it lives in the eligibility and registration family, your fix is training and workflow at check-in, and it's one of the most correctable problems in the whole revenue cycle.
Finding three: the numbers drift from reality.
Payments posted to the wrong claim or the wrong line, remittances that never fully posted, adjustments applied without anyone deciding them. Small errors, but they compound into reports that disagree with what actually arrived, and then decisions get made on numbers nobody should trust.
What it means for you: ask when posted payments were last checked against what the payers actually sent. If the honest answer is a shrug, you've found the third file.
None of the three requires a vendor to fix, and all three are checkable from your own reports. The checklist we use is the same free audit that lives at thepracticeoperator.co/billing-audit, if you'd rather look for yourself before anyone else does.
“IS IT NORMAL?”
One real question from a practice operator, answered straight. Identities stay out of it.
“We got a letter from a payer asking for medical records on about twenty claims. Nothing like this has ever happened to us. Are we in trouble?”
Probably not, and let's take the fear out of it first. Payers run routine post-payment reviews all the time. Claims get pulled for documentation checks by category, by procedure, sometimes close to randomly. A records request, even a batch of them, is usually the system doing what the system does. It reads like an accusation. Most of the time it's an exam.
Two things decide how it goes, and both are in your control. The deadline: the request has one, it's real, and missing it can turn payable claims into denials for non-response, which is the only way a routine review becomes an actual loss. And the completeness: send everything requested, organized, on time, and keep copies of exactly what went out and when.
The operational fix behind the fear is ownership. Payer correspondence needs one named person who opens it the same day, logs every request with its deadline, and routes it. Requests that sit in mail trays are how easy exams get failed.
When does it deserve more attention? If waves of requests keep landing on the same procedure family, that's the payer studying a pattern, and it's worth reviewing how your documentation supports those codes before they finish studying. That review is a Tuesday project, done calmly, not a crisis.
Show your work, on time, every time. That's the whole assignment.
Have one of these questions yourself, the kind you've been staring at alone? Hit reply. Every edition answers one, and nobody will know it was yours.
Talk soon,
Dr. Tarek Shahbandar
Co-founder, Expert Medical Billing · Practicing physician, 25+ years
NEXT EDITION: The vendor questions. What to ask any billing company before you sign with them, including us.