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 programme — 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 programme 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. 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 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-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 visit billed with a well visit on the same day without modifier 25 and separate documentation”
• 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 visit billed with a well visit on the same day without modifier 25 and separate documentation”
• CO-B7 — Provider not eligible that day
  A credentialing or enrollment problem rather than a claim problem: nothing this provider bills to this payer will pay until it is fixed, and it is rarely one claim.
  Recovered by being fixed in credentialing, not on the claim. Matched from: “Newborn claims denied because the baby was never added to the policy inside the enrollment window”

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

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