About the Practice

A busy family care practice in the Phoenix metro area was serving a high volume of patients across multiple providers. The clinic offered primary care, preventive services, and pediatric visits, billing a wide mix of payers including commercial insurance and government-funded programs.

Like many independent practices, they were focused on patient care. Revenue cycle management was running in the background, not performing the way it should.

The Challenge

The practice had an existing billing arrangement in place. But the numbers told a different story.

Claims were sitting in hold buckets for weeks. A significant portion were never submitted at all. Others were billed with the wrong codes, wrong modifiers, or wrong payer sequencing. When denials came back, they were either ignored or adjusted off without review.

The issues ran deep:

• Claims were taking an average of 12 days to submit after lock
• The denial rate was sitting at 33%
• The net collection rate had fallen to 60%
• Days in AR had climbed to 45
• The rate of successful denial appeals was 0%
• Total outstanding AR had reached approximately $2.4 million

Auto-posting was being used without proper oversight. Payable denials were being written off. Vaccine administration codes were billed with incorrect units, wrong routes, and age-inappropriate CPTs. Referral and authorization requirements were not being communicated to the front desk, leading to repeat visits and repeated denials on the same patients.

The practice was losing money on services it had already delivered.

“Providers were not being informed when services required authorization,” noted during the review. “Multiple visits were occurring before the office was even notified.”

The Solution

PMBC conducted a thorough review of the practice’s revenue cycle, going claim by claim to identify patterns, root causes, and missed revenue.

The findings shaped a targeted recovery plan built around three areas:

01 — Claim Accuracy and Charge Capture

PMBC identified that roughly 28% of claims had charge capture issues and 26% had incorrect coding. In several cases, services documented in the progress note were never billed at all.

The fix was methodical. Each claim was reviewed against the progress note. Vaccine components were mapped by route and count. Add-on codes were applied correctly. Modifier use was corrected across high-frequency CPTs to prevent bundling denials and recover reimbursement the practice was already entitled to.

For one pediatric claim alone, the original submission had used adult vaccine administration codes, then incorrect units on resubmission, and still missed the correct route of administration on the third pass. PMBC corrected the coding, applied proper add-on codes, and resubmitted.

02 — Denial Management and Appeals

The practice had a 33% denial rate and a 0% appeal success rate. Denials were coming back and going nowhere.

PMBC put a structured denial tracking process in place. Each denial was categorized by root cause. Payer-specific resolution protocols were developed. CO-97 denials that had been auto-adjusted were flagged and reviewed for appeal eligibility.

A defined list of codes that legitimately bundle was created and shared with the posting team so payable denials stopped being written off by mistake.

03 — Communication and Process Alignment

A major source of repeated denials was a communication gap between billing and the front desk.

Patients on plans requiring referrals were being scheduled for follow-up visits without any notification going to the office. By the time the denial came back, it was sometimes too late to obtain retroactive authorization.

PMBC introduced a billing alert process so the front desk received timely notifications when authorization or referral requirements applied. This stopped the cycle of repeated denials on the same patient for the same reason.

Insurance sequencing errors, eligibility issues, and inactive payer setups were also corrected at the claim scrubbing stage before submission.

The Results

Within the first phase of engagement, PMBC identified and corrected billing errors across hundreds of claims. Payer setups that had been causing blanket rejections for multiple providers were fixed. Claims that had never been submitted were mapped, verified, and sent.

Based on the scope of issues identified and corrections made, PMBC projected a 25 to 30% increase in net collections and a 60 to 70% reduction in denial rates within the first six months of full implementation.

The practice’s clean claims ratio was already at 80%. With the coding, modifier, and charge capture corrections in place, that number had room to climb.

Over the course of the engagement, PMBC:

• Corrected vaccine administration billing across multiple claim types
• Recovered revenue on unbilled and improperly mapped claims
• Reduced the denial turnaround cycle from 60 days
• Established a denial tracking and appeal workflow
• Fixed payer sequencing and insurance setup errors causing repeated rejections
• Closed the communication gap between billing and front desk operations

Conclusion

The practice came in with a 33% denial rate, $2.4 million in outstanding AR, and no active appeal process. Billing was running on autopilot and leaking revenue quietly on every shift.

PMBC went through the work claim by claim. The problems were fixable. Most of the revenue was still recoverable. What was missing was structure, oversight, and a team that knew where to look.

“By taking a proactive approach to your revenue cycle, we can significantly enhance financial performance while reducing administrative burdens.”

That is exactly what the engagement delivered.

Results may vary by practice. Projections are based on findings from the initial RCM analysis and historical outcomes from comparable engagements.

PMBC – Professional Medical Billing Consultants 12409 W Indian School Road, Suite A108, Avondale, AZ 85392 T: 623.322.7436 | info@pmbcenter.com | www.pmbcenter.com