Internal Medicine billing and accounts receivable

Internal medicine carries the widest range of anything on this list — chronic disease, preventive care, procedures in the room — and the losses are spread thinly across all of it rather than concentrated.

Where the money leaks in internal medicine

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.

• Preventive and problem-focused visits billed on the same day without modifier 25
• Chronic care management billed without documented time or consent
• Annual wellness visit and preventive physical treated as the same service
• In-office procedures bundled into the visit by payer edits
• Eligibility not verified, producing denials that were knowable before the patient arrived

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 internal medicine, 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-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: “Preventive and problem-focused visits billed on the same day without modifier 25”
• CO-45 — Charge exceeds the fee schedule
  A contractual write-off rather than a denial. It only becomes a problem when the allowed amount is wrong.
  Recovered by being checked against the contract before any work is done. Matched from: “In-office procedures bundled into the visit by payer edits”
• CO-22 — May be covered by another payer
  The payer thinks somebody else is primary. Until coordination of benefits is corrected on their file, nothing on this claim will pay.
  Recovered by being fixed at coordination of benefits and rebilled. Matched from: “Eligibility not verified, producing denials that were knowable before the patient arrived”

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 internal medicine AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

Questions