By Lemuel Areglo, CPC | Director of Revenue Cycle Management Services
Key Takeaways
- Unresolved denials, infrequent A/R reviews, and aging patient balances can severely impact cash flow. By the time issues become apparent, financial health may already be compromised.
- Many denials are avoidable. Gaps in eligibility, coding inaccuracies, and incomplete information can be addressed before claims are submitted, provided that effective verification and scrubbing processes are in place.
- Patients who are informed of their financial responsibilities beforehand tend to pay more promptly and are less likely to dispute charges. Unexpected bills can lead to dissatisfaction and delayed payments.
- Revenue cycle issues do not arise suddenly. They develop gradually, and by the time they are recognized, cash flow may have already been adversely affected.
This guide addresses common obstacles to effective collections and provides actionable workflows to overcome them. Focus on the section that is most relevant to your current challenges — each is designed to function independently.
Table of Contents
Understanding Surgical Revenue Challenges
The short answer: ownership of the process is often unclear.
Front desk staff may assume that billing will handle eligibility issues, while billing teams rely on complete clinical documentation. This lack of clarity can lead to claims falling through the cracks, resulting in unpleasant surprises when A/R reports are reviewed.
Surgical practices face unique challenges. Surgery billing differs significantly from billing processes in other specialties. A general billing team managing multiple specialties may lack the specialized knowledge needed to identify surgical-specific errors before claims are submitted, leading to compounded issues.
The most common issues include:
- Eligibility gaps — If insurance is not verified prior to the visit, claims may be sent to the wrong payer or denied outright, resulting in delays and resubmissions.
- Documentation deficiencies — Inadequate clinical notes that fail to justify the necessity of a service can lead to payer rejections.
- Coding errors — Incorrect CPT or ICD-10 codes can result in underpayment or denial. Surgical coding requires specialized knowledge that generalist billers may lack.
- Lack of follow-up processes — Claims can age without any follow-up, ultimately missing timely filing deadlines and becoming unrecoverable.
Creating a Proactive Denial Management System
Denial management should be viewed as a systematic process, not merely a cleanup task.
Prevent denials before submission
Most denials can be prevented. The primary reasons — missing information, eligibility issues, and coding errors — can all be identified before claims leave your system.
Verify insurance eligibility prior to every appointment, not just at check-in. Confirm the payer, plan type, copay, deductible status, and any prior authorization requirements, and document this information.
Utilize claim scrubbing before submission. Your billing software should identify missing modifiers, bundling issues, and frequency limit violations. If it fails to do so, you risk sending out claims that are likely to be denied.
Identify denials immediately
When a denial is received, it should be routed the same day. Every hour it remains unaddressed brings you closer to missing a timely filing deadline. Categorize denials by reason code — eligibility, authorization, coding, documentation, or duplicate — and track patterns. If one provider has a higher denial rate than others, it may indicate a documentation issue. If a specific payer denies more frequently, it could signal a contract issue.
Resolve within 48 hours
Aim to resolve denials within 48 hours of receipt. If a denial cannot be resolved at the first level, escalate it promptly and avoid letting it linger. Document the resolution steps for each denial type to ensure staff are not reinventing the process each time.
Effective A/R Follow-Up Strategies for Surgeons
The reality is that reviewing A/R once a month is insufficient; true follow-up requires weekly attention, prioritizing claims based on age and dollar amount.
Collection probability diminishes significantly as claims age. Claims under 30 days have a collection rate above 95%, while those over 120 days may drop below 50%. Each week of inaction decreases your chances of recovery.
A straightforward weekly routine:
- Day 1 — Review claims aged 0–30 days. Confirm receipt and ensure claims are being processed.
- Day 2 — Address claims aged 31–60 days. Contact payers regarding any claims with no activity. Document every interaction.
- Day 3 — Escalate claims aged 61–90 days, as they are nearing critical age.
- Day 4 — Take aggressive action on claims over 90 days. Check for timely filing proximity to prevent these claims from being lost.
- Day 5 — Follow up on patient balances and initiate discussions about payment plans.
KPIs to track:
Metric
Target
Days in A/R
Under 35
A/R over 90 days
Under 15% of total
Clean claim rate
95%+
Denial rate
Under 5%
What's Slowing Down Your Claims
Inefficiencies in billing often stem from role confusion or errors during intake.
When one individual manages registration, eligibility, charge entry, and follow-up, accountability diminishes. It is crucial to separate front-end tasks (registration, eligibility, authorization) from back-end tasks (coding, billing, A/R), even in smaller practices.
Another significant issue is poor data collection at intake. Incorrect insurance IDs, demographic errors, and missing authorization numbers can lead to claims failing downstream, often when the visit is weeks old and documentation is no longer fresh.
Advanced EHR vendors offer AI-powered intake platforms that can enhance intake accuracy and alleviate front desk bottlenecks, ultimately reducing the incidence of poor data collection that hampers claims processing.
Verify before the appointment:
- Patient demographics
- Active insurance coverage and effective dates
- Copay, deductible, and coinsurance status
- Prior authorization (if required)
- Estimated patient responsibility communicated to the patient
Submit claims daily rather than in weekly batches. Daily submissions allow errors to be identified while the encounter is still fresh and catch clearinghouse rejections early — a rejected claim will not be in the payer’s queue at all.
Enhancing Patient Communication for Better Collections
With the rise of high-deductible plans, patient financial responsibility has increased significantly. Collecting these amounts requires a different strategy than collecting from payers.
The key factor is not the design of your statements but the conversations held prior to the visit. Patients who understand their financial obligations in advance are more likely to pay promptly and are less likely to dispute charges. Conversely, patients who receive unexpected bills are less likely to pay and may not return for future services.
Collect copays at check-in. Send statements within a week of claim adjudication. Facilitate easy payment options online, via phone, text-to-pay, and offer payment plans for larger balances. Patients who have multiple payment options are more likely to utilize them.
A basic outreach cadence:
- Statement sent at day 0 (post-adjudication)
- Reminder sent at day 30 (statement + email or text)
- Phone call made at day 45
- Final notice issued at day 60 with a payment plan offer
- Consider collections at day 90
Document every attempt. A thorough paper trail is essential if an account eventually goes to collections.
Quick-Reference Checklists
Pre-visit
- Demographics verified
- Eligibility confirmed
- Benefits documented
- Authorization obtained (if required)
- Patient informed of estimated cost
Claim submission
- All fields complete
- Diagnosis codes support medical necessity
- Procedure codes align with documentation
- Modifiers applied correctly
- Claim scrubbed
Denial management
- Denial identified within 24 hours
- Reason code categorized
- Resolution initiated within 48 hours
- Appeal filed (if applicable)
- Root cause logged for pattern tracking
Patient collections
- Copay collected at time of service
- Statement sent within 7 days of adjudication
- 30-day reminder dispatched
- 45-day phone outreach attempted
- Payment plan offered before day 60
The Integration Problem Most Practices Ignore
Many billing inefficiencies arise from poor handoffs rather than personnel issues. When clinical documentation, practice management, and billing operate in separate systems, data must be re-entered, leading to errors and missed charges.
WRS Health integrates all three functions within a single platform. When a provider completes an encounter, billing processes begin immediately with complete clinical context — eliminating the need for exports, manual entries, and gaps in information. For practices seeking further support, Surgery-Cloud Billing Services provides dedicated specialists who understand your specialty, adhere to a weekly A/R cadence, and identify denial patterns before they escalate into revenue issues.
If your in-house billing team is struggling with high volumes, increasing denial rates, or staff turnover affecting continuity, it may be time to consider outsourcing as a viable solution.
The workflows outlined above are effective. The question is whether your current setup can support them. If it cannot, it may be time for a thorough evaluation.
Talk to our billing team for a FREE billing analysis.
Lemuel Areglo, CPC
is the Director of Revenue Cycle Management Services at WRS Health, bringing nearly 15 years of experience leading medical billing, coding, credentialing, and revenue cycle operations across the healthcare industry. Lemuel’s expertise spans the full revenue cycle, including claims management, denial resolution, payment posting, accounts receivable, and practice operations. He has extensive experience supporting various specialties, including surgery, psychiatry, physical therapy, pain management, internal medicine, orthopedic surgery, speech therapy, and sleep medicine.
