My team and I were discussing another article on the difficulties with physician reimbursement. Here is a statistic that stuck with me. 1 in 8. That is how many physician consult claims many practices are losing. It’s not because the consult did not meet criteria or the consult didn’t happen, but because, somewhere between the phone call and the billing desk, the paperwork fell apart.

Hello again. Welcome back to the Connected Practice, a ClinicianCore series of podcasts. I’m Dr. Kevin Halow, surgeon, veteran, co founder, and Chief Medical Officer of ClinicianCore. In today’s podcast, we’re going to dive into that statistic, 1 in 8. We’re going to think about that in terms of your own patient volume and discuss why this is real revenue that you are missing. It is a statistic that insurance companies love because they and their shareholders are getting free labor from you. On the other hand, for you, it’s just more work that you’ve done and intellectual wealth that once again, you’re giving away with nothing in return.

The Hidden Problem with Claim Denials

I have spent most of my career split between different identities. A surgeon, an officer, and a small business owner. As part of my duties, I have also had to spend time on claim denials. Which is not what I signed up for in medical school. But here’s what my time in the operating room and the offices taught me. The clinical work isn’t always the problem. The problem can be everything around it.

You see, a consult happens. A specialist calls back with clearance. A note gets dictated. And then that note has to survive this crazy relay race through a scheduler, through a biller, through a coder, through a payer’s own internal review before anyone gets paid for the work that has already happened. And, if one runner in that relay race drops the baton, the claim doesn’t just get delayed, it gets denied. And a denied consult claim doesn’t usually get revisited. It gets written off, quietly, months later by someone who wasn’t even in the room when the consult happened.

That’s the hidden part. It’s not a dramatic failure. It’s a number of small, individual hand offs. And the 1 in 8 is just what happens when enough of them slip by.

The Myth of Self Reliance

I was trained to be self reliant. You’re taught over and over that the decision is yours, and the outcome is yours. Yeah, there’s some truth in that. But it’s not quite accurate because, there has never been a time that I fixed a patient by myself. I’ve always had a team. For example, in the military, a trauma case wasn’t one surgeon being a hero. It was a hand off from the medic in the field, to the team that stabilized the patient, to me and the team in the trauma bay and the operating room, to the nurses in recovery and the ICU. Every one of those hand offs had to be clean or the whole chain broke down.

The hand offs themselves were as important as the surgeries. I carried that into civilian practice and honestly it took me a while to notice that most independent practices don’t emphasize that hand off at all. We concentrate on the diagnosis and the surgery. But is anyone really triple checking that fax or the call back that never comes? The same profession that demands surgical precision can let a consult note sit in a queue for 4 days and not think that could be a problem.

A Real World Example

Let me give you the version of this that I have actually lived, both on the surgery side and the administrative side. So, one of the neurosurgeons asked me to do a co surgery with her, an L5 S1 anterior lumbar interbody fusion. That is a lot of coordination. Both my office staff and hers needed to get the pre authorization done, the schedules coordinated, and the patient on the schedule. In addition, the patient needs medical clearance from the patient’s primary care physician, the anesthesiologist needs the patient’s full medication list, and finally, the operating room needs a scheduled date and time.

In the old workflow, that is countless phone calls, emails, faxes, and communications across different EMR systems. All of that information may or may not land, despite the surgery schedulers persistent calling to check to see if anything moved. Often it takes one bottleneck. For example, if the primary care office is behind because they are swamped, no one in the practice even knows that there’s a problem until the day before surgery.

This is just not a paperwork issue anymore. It’s a canceled OR slot, a patient who took the day off of work for nothing, two surgeons who have both of their busy schedules disrupted, and many different staff members spending a full day untangling a mess that a shared, trusted channel would have flagged 4 days earlier.

That’s the pattern behind the 1 in 8 number too. It’s the same missed hand off, just wearing a billing code instead of a surgery schedule.

The ClinicianCore Solution

So, what can change all this? What eliminates that 1 in 8 loss? Well, here’s a thought, how about make it automatic. Once the consult request, the specialists response, and the timestamp on every step is captured automatically in one shared record, the billing team has everything they need to send a clean claim the first time. Not eventually, but on the first pass.

That’s not a billing fix, that’s a communication fix that happens to show up on a billing statement. When every consult is verified, routed to the right queue, and documented the moment it happens, you stop reconstructing what happened 3 weeks later from memory and sticky notes. You already have the record. There are fewer denials, fewer appeals, and physicians that stop getting pulled back into billing disputes for patients they treated months ago.

My co founder and I did not build ClinicianCore because we wanted to think about consult claims. We built it because I was tired of watching good clinical work get lost in a hand off that no one was actually watching. ClinicianCore’s HCO Practice HQ exists so that every consult, the request, the response, the record, lives in one trusted place from the moment it starts to the moment it is billed.

If your practice has a number like 1 in 8, or worse, sitting somewhere in your billing reports, it’s not a staffing problem, it’s a hand off problem. And hand offs, I promise you, are fixable.

Closing Remarks

If you’re ready to see how ClinicianCore’s HCO Practice HQ can revolutionize your billing and coding department, come check it out at cliniciancore.com. While you’re there, sign up for our waitlist for our upcoming September release. You can also check out our many podcasts, webinars, blogs, and white papers.

I’m Dr. Kevin Halow, co founder and Chief Medical Officer of ClinicianCore. It’s time to start making the insurance companies pay for the services that you provide so well. Thanks for listening.