Family Practice billing and accounts receivable

Family practice sees every age group under one roof, which means paediatric vaccine rules, adult preventive schedules and geriatric wellness rules all apply in the same clinic on the same day.

Where the money leaks in family practice

These are the recurring denial reasons in this specialty. They are not exotic. They are the ordinary ones that go unworked because the person who could fix them is at the front desk answering a phone.

• Vaccine administration and product codes mismatched across age groups
• Preventive visit frequency counted by plan year by the payer and by birthday by the practice
• Sick and well visits on the same day without separate documentation and modifier 25
• Screening versus diagnostic coding wrong, moving a covered service to patient responsibility
• Referral requirements missed on plans that need one before a specialist visit

What a seat does about it

One trained person works your queue from the difficult end. Every call is logged with the payer reference number and the outcome, so an appeal can quote what was said rather than start again. Denials are categorised, which is how the same reason stops coming back next month. On Friday you get it in writing.

The roles that matter most in this specialty are AR calling and denials at $1,700, prior authorization at $1,900, and certified coding at $2,500.

The codes those turn into

Each of these is a denial code you are likely to meet working family practice, matched to the problem above it in your own words. The route back to payment differs by code, so a queue sorted by recovery route clears faster than one sorted by date.

• CO-50 — Not deemed medically necessary
  The payer does not accept that the documentation supports the service. This is a clinical argument, not a clerical one.
  Recovered by being appealed with clinical documentation. Matched from: “Sick and well visits on the same day without separate documentation and modifier 25”
• CO-16 — Claim lacks information
  Something on the claim is missing or malformed. On its own the code tells you nothing — the detail is in the remark code that comes with it.
  Recovered by being corrected and resubmitted. Matched from: “Sick and well visits on the same day without separate documentation and modifier 25”

Working a denied claim costs $57.23 per denied claim in administrative time (source), and about about 90% of initially denied claims are eventually paid. Most of what sits in a family practice AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

Questions