The Problem
A solo specialty provider was seeing a full schedule of patients but consistently coming up short on collections. The books looked healthy—patients were being seen, procedures were being done—but the bank account told a different story.
The practice had no system for tracking what happened to claims after they were submitted to insurance. Denied claims were piling up unopened. Claims from two major insurance companies had been sitting in "pending" status for months with no follow-up. The provider assumed the billing service was handling it. The billing service assumed the provider was aware.
Nobody was watching the money between "service rendered" and "payment received."
The Approach
Claims review
- Pulled 12 months of billing data and sorted every denied claim by reason, insurance company, and procedure code
- Found that 18% of all claims were being denied—nearly triple what a well-run practice should expect
- Identified the top 5 reasons claims were getting denied, which accounted for 80% of all denials: missing information on the claim, patient eligibility issues, late submissions, missing prior authorizations, and coding errors
Stuck claims
- Contacted the two major insurance companies directly to investigate 43 claims that had been sitting in "pending" for 60 to 180+ days
- Found that most of these just needed simple paperwork corrections or resubmission—not clinical disputes
- Set up a weekly check on any claim that's been pending more than 30 days, with an escalation plan at 45 days
Fixing the process
- Added a pre-visit check to verify patient insurance eligibility and get authorizations before the appointment—catching the most common denial triggers before the patient even walked in
- Created a weekly Monday morning denial review: look at new denials, figure out why, and resubmit corrections the same week
- Built a simple dashboard so the provider could see, for the first time, how many claims were denied, by which insurance company, and how long it was taking to get paid
Insurance company negotiations
- Found that one insurance company was consistently underpaying on a high-volume procedure and requested a fee schedule review
- Negotiated a corrected reimbursement rate that increased payment per procedure by 12%
What Made It Work
The biggest finding wasn't complicated—it was that nobody was looking. The practice was submitting claims and assuming they'd get paid. When we actually tracked what happened after submission, we found six figures in revenue sitting in denied and stuck claims.
The pre-visit eligibility check was the single highest-value change. Most denials were completely preventable with information that was available before the patient's appointment. Catching those issues upfront eliminated the majority of denied claims.
What This Means for Your Practice
If you don't know your denial rate, how long it takes to get paid, or how many claims are stuck with insurance companies, you're almost certainly leaving money on the table. Most solo and small practices have never done a thorough claims review. The ones who do consistently find $50K–$200K+ in revenue that was already earned but never collected.