Pediatrics billing and accounts receivable

Pediatrics runs on well-child visits, immunisations and a vaccine inventory that is half purchased and half supplied by a federal program — and the two are billed completely differently.

Where the money leaks in pediatrics

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 billed without the matching product code, or the reverse
• Vaccines for Children stock billed as purchased vaccine, which is a program violation as well as a denial
• Well-child visit denied for frequency when the payer counts by plan year and the practice counts by birthday
• Sick visit billed with a well visit on the same day without modifier 25 and separate documentation
• Newborn claims denied because the baby was never added to the policy inside the enrollment window

What a seat does about it

One trained person works your queue from the difficult end, from our office in Rawalpindi, Pakistan, logged into your own system on your hours. 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. Some payer contracts and some state Medicaid programs restrict or require disclosure of offshore access — check yours before placing a restricted queue on this seat (more on /security/).

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

The codes those turn into

Each of these is a denial code you are likely to meet working pediatrics, 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-151 — Too many services billed
  The payer accepts the service but not the quantity or the frequency at which it was billed.
  Recovered by being appealed with clinical documentation. Matched from: “Well-child visit denied for frequency when the payer counts by plan year and the practice counts by birthday”
• CO-4 — Modifier and code disagree
  The code and the modifier disagree, or a modifier the payer required was not there.
  Recovered by being corrected and resubmitted. Matched from: “Sick visit billed with a well visit on the same day without modifier 25 and separate documentation”

Working a denied claim costs $57.23 per denied claim in administrative time (source), and payers ultimately pay roughly 90% of claims even while using an initial denial to slow payment. Most of what sits in a pediatrics AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

Questions