Primary Care billing and accounts receivable

Primary care runs on volume — wellness and preventive visits, same-day acute complaints, chronic disease follow-up, immunisations, in-office labs and care management between visits. Individual claims are small, many carry several separately payable lines, and one encounter often mixes preventive work with problem work, so revenue leaks in ones and twos rather than in one large denial.

Where the money leaks in primary care

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.

• A preventive visit and a same-day problem visit written up in one undivided note, so the problem visit bundles into the wellness visit and is not paid separately.
• A wellness visit denied on frequency because nobody checked the date of the last one before the appointment was booked.
• Vaccine administration billed without the product line, or a state-supplied vaccine billed as though the practice had bought and stocked it itself.
• Care management billed for a month with no time log in the chart, no documented patient consent, or another practice already billing that patient for the same month.
• A patient billed as new when a partner of the same specialty in the same group had already seen them within the past three years.
• Low-dollar denials — the patient assigned to a different primary care provider, a wrong place of service — left in the queue as not worth the call, then aged past timely filing.

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 primary care, 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-97 — Payment included in another service
  The payer is bundling this code into another one on the same claim. Sometimes that is correct and sometimes it is not.
  Recovered by being worked at the edit pair, with a modifier only where the record supports one. Matched from: “A preventive visit and a same-day problem visit written up in one undivided note, so the problem visit bundles into the wellness visit and is not paid separately.”
• 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: “A wellness visit denied on frequency because nobody checked the date of the last one before the appointment was booked.”
• CO-29 — Time limit for filing has expired
  The claim arrived after the payer’s filing deadline. This one is usually terminal, which is why it deserves attention before it happens rather than after.
  Recovered by being prevented rather than recovered. Matched from: “Low-dollar denials — the patient assigned to a different primary care provider, a wrong place of service — left in the queue as not worth the call, then aged past timely filing.”

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

Questions