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. 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 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-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: “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-252 — Additional documentation required
  The payer will not decide until it sees paperwork. Nothing happens until it arrives.
  Recovered by being answered with the document the payer names. 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-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: “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.”
• 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: “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.”
• 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: “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.”
• 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 about about 90% of initially denied claims are eventually paid. 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