The Connected Practice

Claim Denials Start Before The Bill: 5 Handoff Gaps

Hosted by Dr. Kevin Halow, MD MBA FACS

S3 · Ep11 · 14:33

What You'll Learn in This Episode

Revenue leakage starts as a communication event

Unbilled services, unappealed denials and held payments look financial. Followed back, most begin with a question that was never answered.

Independent practices feel the gap most

Small teams and outside billing partners mean the person with the question often cannot reach the physician who holds the answer.

Five handoff gaps hold up claims

Credentialing and registration, prior authorization, coder queries, unbilled consults and denials that wait on the physician's input.

A compliant query still has to reach the physician

ACDIS and AHIMA query guidance says a query should not lead or mention payment. It also needs a channel the physician actually sees.

One recorded channel, not a new billing system

Route each billing question to a named person, track it from sent to closed, and share the data with your billing partner every month.

About This Episode

Claim denials rarely start in the billing office. In this episode of The Connected Practice, Dr. Kevin Halow, MD, MBA, FACS, follows them back to a question that never reached the physician: a coder asking about laterality, an authorization needing notes, a denial waiting for a clinical explanation. He walks through five places independent practices lose revenue before a claim goes out, from credentialing and prior authorization to coder queries, unbilled consults and slow denial responses, and explains how one recorded, HIPAA-compliant channel with a named owner for each question is built to close those gaps.

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Transcript

Claim Denials Start Before The Bill: 5 Handoff Gaps

0:04

Picture a Tuesday afternoon in a small orthopedic practice. A coder is finishing a claim and hits one gap in the note. Is it left knee or right knee? Well, the physician could answer it in seconds. However, good luck getting a chance to talk to her. She's currently seeing a line of patients in the office, and then she has to run to the hospital to fix that add-on patient, an ORIF that came in from the ER last night. She's already going to miss another quality meeting, but she is determined to make her daughter's soccer game, since she missed the last two. The question lands in the usual spot, in an inbox buried under 40 other messages. These are really important messages, like "Marie in billing is out early today," or

0:49

"John from scheduling has a dental appointment," or the best one, "Potluck Friday at the Galena office." So the claim goes on hold. A week passes, then two. So much for that income. Nobody made a billing mistake per se. It's just that rate-limiting question simply never reached the right person. Hi, I'm Dr. Kevin Halow, Air Force veteran, surgeon, co-founder and chief medical officer of ClinicianCore. In this episode, "Clinical Handoffs, Claim Denials: How Revenue Leakage Starts Before the Bill," we expand upon a ClinicianCore article that was written by our CEO, Neeraj Jain.

1:34

If you own, run or bill for an independent practice, this podcast is for you. Let's start with a definition. Revenue leakage is the gap between what a practice should be paid for the care which it delivers and what the practice actually collects. These include claims denied and never appealed, services never billed, payments held by an enrollment issue, and balances written off because follow-up took too long. Your finance staff may record all of that as a financial event. The reality is that if you follow it back far enough,

2:19

you will find that it's usually a communication event: a coder who needed a detail, an authorization person that needed notes, a denial that needed the physician's explanation. The numbers back this up. In a January 2026 MGMA poll, 48% of medical group leaders named denials and appeals as their biggest revenue cycle leak. On the other hand, front-end issues came in at 23%. Premier found that nearly 15% of claims sent to private payers were initially denied. More than half of those were later overturned and paid. Providers still spent an average of $43.84

3:05

per claim contesting them. Despite the fact that the care was legitimate and the payment was owed, the practice paid to prove that fact. Moreover, Experian Health's 2025 survey found that 41% of providers had denial rates of 10% or higher, with half naming missing or inaccurate data as a leading cause. To be clear, missing data is not a billing problem. It's a communication and handoff problem. Independent practices run the revenue cycle with fewer people and less slack. The AMA reports that 47% of physicians work in practices of 10 or fewer people.

3:53

In these practices, the person who answers the phone may also verify insurance. The biller is likely the person that often works closely with the outsourced revenue cycle management, or RCM, company. While that arrangement is not unreasonable, it also creates a structural gap. For example, the billing partner can see that a claim is stuck but cannot always reach the physician who holds the answer. So the request goes by phone, voicemail, fax, email or the EHR inbox, competes with patient care, and leaves almost no trail. In my practice, I frequently receive queries on patients or cases that are months old. These all represent money that I have earned but may or may not receive

4:42

because of denials based upon missing information. Now think about your practice. If your biller needed one answer from you today, where would that request land? And how would anyone know it was still open next Friday? It may seem innocuous, but it's not. This leak can turn good care into unpaid care. If a physician's payer enrollment is incomplete or lapses, you can deliver the service and not be paid for it. In addition, CMS requires most providers to revalidate Medicare enrollment every five years. Typically, they post due dates about seven months ahead. If these lapse, it can negatively affect the RCM.

5:29

CMS does not pay for services furnished while billing privileges are deactivated. To counter this, the credentialing team usually knows what it needs: an updated license, a signature, a new location. Still, the delay in reaching the physician and confirming the answer can mean the difference between being paid or not. Adding to that, registration errors, front-end mistakes made during patient intake, such as entering the wrong name or birth date or insurance details, regularly cause insurance claim rejections or payment delays and lost revenue. In Experian's survey, 32% of providers named registration errors as the top cause of denials. Finally, charge capture errors, meaning

6:15

services performed but never entered, or patient balances not collected at the visit, also lead to lost income. Of course, our discussion of how we do not get paid would not be complete without a mention of the prior authorization rabbit hole. In 2025, the AMA surveyed 1,000 physicians. On average, there were about 40 prior authorizations per physician per week that required attention, which represents about 13 hours of physician and staff time. 95% of respondents stated that the delays hold up care. To add more administrative burden to your already overflowing plate, the CMS rules

7:02

on prior authorizations are changing. As of January 2026, under CMS-0057-F, impacted payers, including Medicare Advantage plans and Medicaid and CHIP programs, must answer expedited prior authorization requests within 72 hours and standard requests within seven calendar days. Oh, don't worry. It gets worse. Just when you thought the administrative bureaucracy could not do any more to prevent you from being paid, CMS has struck again. In January 2027, prior authorization requirements, documentation and decision APIs will become even more onerous. So at the end of the day, it's all about conveying the right clinical

7:50

detail from the physician to the billers and coders, then to the insurance carrier. If that takes four days, a seven-day payer clock does not help much. Now, let's circle back to my opening story. When a note is incomplete, the coder has to stop and ask. Until the physician answers, the claim waits in an inbox and no money is received. In the CMS 2025 supplemental improper payment data, insufficient documentation accounted for about half of Medicare fee-for-service improper payments. Incorrect coding accounted for 11%.

8:35

MGMA members also named insufficient documentation and Modifier 25 among their most common denial causes. Most coder questions are routine: laterality, diagnosis specificity, whether a separately identifiable service supports a modifier. How the question is asked matters. The Association of Clinical Documentation Integrity Specialists, ACDIS, and the American Health Information Management Association, AHIMA, guidelines for compliant query practice say a query should not lead the physician towards an answer or mention financial impact. So, for example, a good query would say,

9:22

"The note does not specify laterality. Please clarify." You can't say something like, "Document the more specific diagnosis so we get paid at a higher level." You can't say that. But to get an answer, the query has to reach the physician. When your communication exists in the fog of war, that simple task can be really difficult. As if I have not depressed you enough already, there are still even more ways in which you're not being paid. As an example, physicians consult each other constantly: a call about a lab result, a quick question about a treatment plan.

10:07

CPT has interprofessional consult codes for this work, 99446 to 99449, plus 99451 and 99452. And Medicare added matching codes for behavioral health practices in 2025. When a consult happens informally, the request, the consent, the consult time, the written report time, all that goes unrecorded. And unrecorded work cannot be reviewed for billing. No documentation and no billing means no money. While the requirements are specific and coverage varies by payer, we as physicians are routinely leaving money on the table in terms of billable hours. Capturing those hours is money in our pocket.

10:54

Your malpractice attorney just bought that new BMW X7, and you're still driving that same old Jeep with 150,000 miles, and you wonder why. Ironically, many denials are recoverable, but only with clinical input: a medical necessity explanation, a missing note, a more specific diagnosis. The MGMA found that 60% of group leaders saw denials rise in early 2024. Every day spent chasing a physician for an answer is a day the denial ages towards its appeal deadline. Remember: no documentation, no billing, no money. You keep driving that same old Jeep until you get to 200,000

11:41

miles or more. I know that these discussions are difficult, but the reality is, there is still a light at the end of this long tunnel. All of these issues that we've discussed are centered around one problem: communication. Communication that is scattered, fragmented and difficult to track. It's not your billing system. You don't need a new billing system. You just need one unified communication platform. When you change the narrative and force all of these questions, queries and issues to travel to one recorded, private, HIPAA-compliant communication channel, everything changes. You and your billing partner can see which payers, services and documentation gaps

12:29

keep returning, and fix them at the front end instead of re-fixing the same problems over and over again. A single recorded communication channel allows you to stop the query delays, which speeds up claims. Route issues to a named person, and track them through the process of sent, to viewed, to answered, to closed. Use a HIPAA-compliant channel covered by a business associate agreement, with access limited to the people who need it. And rapidly and consistently share data with your billing partners. In short, rather than a big transformational project and a whole new billing system, it's just a new habit of better communication.

13:15

Okay, that's all we have for today. The full article, with all the references behind every number that we listed in the podcast today, is linked in the show notes. You can also learn more about ClinicianCore, our secure, HIPAA-compliant, unified communication platform built for physicians by physicians. ClinicianCore gives the practice, its staff and the billing partners one recorded channel for these questions, which is what medical practice efficiency should look like today. To see how ClinicianCore handles a question from a coder's query to a released claim, request a live demo at cliniciancore.com. I'm Dr. Kevin Halow, co-founder and chief medical officer of ClinicianCore. I'm going to leave you with one challenge for this week.

14:00

Pick one stuck claim and trace it backwards. Find the question that started it. Then ask: who was waiting on it? Now imagine if that answer had come instantly. How would that have changed things, and put more money in your pocket? Thanks for listening.

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