On the billing side, a practice increases revenue by collecting, correctly, what it has already earned: every visit becomes a charge, every charge is coded to the documentation, claims go out clean and on time, denials and underpayments are worked, and patient balances are collected. It does not come from coding higher than the record supports. That is overcoding, and the money it brings in has to be paid back.
Other revenue levers sit outside billing: payer contracts, provider enrollment, scheduling and the services the practice offers. This guide covers billing, and points to those at the end. Payer rules vary, and reimbursement depends on each payer's contract and fee schedule. Where a specific rule is quoted, it is Medicare's or Medicaid's, and it is cited at the end.
Where does a practice lose revenue it has already earned?
Revenue slips out of the billing process in a few predictable places:
| Where it leaks | What it looks like | Where it's found |
|---|---|---|
| Missed charges | A visit, procedure or supply that was never billed | Schedule-to-charge reconciliation |
| Undercoding | Codes below what the record supports | Coding audit against the records |
| Avoidable denials | Eligibility, authorization, registration or coding errors | Denial log by reason code |
| Late filing | Claims or appeals past the payer's deadline | Unbilled and open-denial aging |
| Underpayments | Allowed amounts below the contracted rate | Payment checks against contracts |
| Unworked A/R | Unpaid claims with no follow-up | A/R aging by payer |
| Uncollected patient balances | Copays and deductibles never collected | Patient A/R, time-of-service collections |
The steps below take these one at a time.
1. Measure before you change anything
Start with a baseline: denials by reason, accounts receivable by age and payer, days from visit to claim, and a small audit of charts against claims. The HHS Office of Inspector General's compliance guidance for physician practices recommends exactly this kind of baseline audit, followed by periodic audits. Without a baseline, you can't tell whether a change helped. The medical billing KPIs guide explains the measures.
2. Protect the front end
Many avoidable denials start at registration and scheduling. Check eligibility and benefits before every visit (electronically, with the HIPAA-standard 270/271 transaction), confirm which plan pays first, and check whether the service needs prior authorization when it is scheduled. The guide to why insurance claims get denied maps each denial reason to the step that prevents it.
3. Capture every charge
Compare each day's completed appointments with the charges entered, and track the time from visit to charge. A charge that is never entered doesn't appear on any denial report, so this check is the only way to find it.
4. Code to the documentation, in both directions
Accurate coding means the codes match what the record supports: not lower, not higher.
- Undercoding leaves payment for work that was done and documented uncollected.
- Overcoding, unbundling and unsupported modifiers bring in money the practice isn't entitled to. The OIG lists upcoding, unbundling and misuse of modifiers among the main billing risk areas for physician practices. Medicare requires an identified overpayment to be reported and returned, generally within 60 days of identifying it.
Revenue that has to be refunded is a liability, not revenue. Regular coding audits, with feedback to clinicians and coders, protect against both errors.
5. Submit clean claims, on time
Scrub claims against payer edits and CMS's National Correct Coding Initiative (NCCI) edits before submission, work rejections daily, and keep a table of filing limits by payer. Medicare's filing limit is generally 1 calendar year after the date of service. Federal Medicaid rules cap the window at 12 months, and commercial limits are set by each plan's contract. Clean claims also get the shortest payment deadlines: Medicare must pay or deny a clean claim within 30 days of receipt. See what a clean claim is.
6. Work denials to their cause
Correct and resubmit what was wrong, appeal what you disagree with, and record why each denial happened. Then fix that step. The OIG guidance recommends reviewing the practice's denial history and correcting the most frequent sources of denials. Appeal deadlines matter too: a Medicare redetermination must be requested within 120 days of receiving the initial decision.
7. Check payments against your contracts
Compare what each payer allowed with the rate you agreed. For Medicare, the rates are in the CMS Physician Fee Schedule look-up. For commercial payers, they are in your contracts. Underpayments look like ordinary adjustments unless someone checks.
8. Work A/R by age and deadline
Follow up on unpaid claims from an aging report grouped by payer and reason, before appeal and filing limits pass. How to read an A/R aging report explains the report.
9. Collect patient balances early and clearly
Estimate the patient's share from the eligibility response, collect known amounts at check-in, and send statements that explain what the plan paid. Clear statements help patients understand what they owe and why. Uninsured and self-pay patients who schedule at least 3 business days ahead are generally entitled to a good faith estimate of expected charges.
What about revenue levers outside billing?
Billing collects what the practice's contracts and services allow. Payer contract terms, the payers a provider is enrolled with (see credentialing and contracting), scheduling capacity and the practice's service mix all shape revenue too. They're separate projects from billing, and worth reviewing once billing is collecting what it should.
Common mistakes to avoid
- Chasing a single number (such as collections) without looking at denials and A/R age behind it.
- Fixing denials claim by claim without fixing their cause.
- Treating coding as a revenue lever rather than an accuracy task.
- Leaving credit balances and overpayments unreviewed.
The guide to common medical billing mistakes goes through these in more detail.
Where to start
Pick the two or three leaks your baseline shows are largest and fix those first. If you'd like help finding them, Highview's medical billing team can start with a free call, and the free revenue audit explains what a review of your data involves.
Sources
- HHS-OIG, Compliance Program for Individual and Small Group Physician Practices (65 FR 59434, October 5, 2000): baseline and periodic audits, denial review, coding and billing risk areas.
- eCFR, 42 CFR 401.305: reporting and returning Medicare overpayments.
- CMS, Medicare Claims Processing Manual, Chapter 1: §70 (timely filing), §80.2.1.1 (payment ceiling for clean claims).
- eCFR, 42 CFR 424.44: Medicare time limits for filing claims.
- eCFR, 42 CFR 447.45: Medicaid claim submission within 12 months.
- eCFR, 42 CFR 405.942: time frame for a Medicare redetermination request.
- eCFR, 45 CFR Part 162: HIPAA standard transactions.
- CMS, National Correct Coding Initiative edits.
- CMS, Search the Physician Fee Schedule.
- CMS, Good faith estimates.