A nationwide practice was waiting 81 days for insurance to pay. We cut it to 40.

The situation

A practice that sees patients across the country and bills payers in multiple states, each with its own rules on medical necessity, prior authorization, and timely filing. The billing company handled the first pass well. What it could not do was keep chasing every out-of-state denial once newer claims needed its attention, so claims that were still open at 90 days tended to stay open and unresolved.

The practice did not want to change billing companies. It wanted a second set of eyes on the claims that were stuck, and it wanted to know why they were getting stuck.

What we did

• Took the claims at 90 days. Any insurance-responsibility claim still open 90 days after the date of service came to us. The billing company's work on everything newer continued unchanged.
• Sorted every claim by what was wrong with it. Our software read each claim, the remittance, and the payer's policy, and flagged the ones with a recovery worth pursuing. Our team confirmed each one before anyone acted.
• Rebilled or appealed, inside the deadline. Corrected claims went back out; wrongly denied claims went to appeal with the records attached and the payer's own policy cited.
• Followed the money that had gone missing. Some claims had been moved to patient responsibility but never reached the patient billing cycle. Some insurers had paid, but to banking details that were wrong, so the funds never arrived. We found both and put them right.
• Reported the payer trends every month. Which denial reasons were growing, from which payers, and what the front end could change.

What happened

Across the whole practice, not just the claims we worked, average time to insurance payment fell by half, from 81 days to 40. Of the insurance-responsibility claims placed with us, 45% turned out to have a possible recovery worth pursuing through rebilling or appeal. By the end of the year those claims had sorted out like this:

Each claim identified as worth pursuing brought in an average of $133 more from insurance, which is 28% of the charges that were eligible to be recovered. That money had already been through a first pass, and would otherwise have aged out or landed on a patient's bill.

The year was not an easy one

Over the same twelve months the practice's payer mix got harder. Claims sent to patient responsibility rose 84% practice-wide, medical necessity denials rose 75%, and prior authorization denials rose 38%. The recoveries above were made against that current, and the monthly trend reports gave the practice the specifics to take back to its front desk and its billing company.

Two problems nobody had seen

• Claims stuck between insurance and the patient. A set of claims had been marked patient responsibility but never made it into the patient billing cycle. No statement went out, so nothing was ever collected. We found them and moved them along.
• Insurance payments that never arrived. Several payers had paid, but to incorrect banking details, so the practice never received the funds. We traced the payments and had them reissued.

Neither shows up as a denial. Both show up as revenue that quietly never arrives, and both are the kind of thing a second set of eyes on closed-out claims is for.

What this suggests for a provider like you

If your patients come from more states than your billing team has payer contacts in, your claims at 90 days are not one problem. They are many small ones, and the ones your team can't reach are the ones that get written off or passed to the patient. A review of what is still open at 90 days, sorted by what is actually wrong with each claim, will show how much is still inside the appeal window. It also tends to turn up the money that was paid to the wrong account.

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