A Phoenix 2-dentist PLLC had outsourced billing for 3 years with no audit oversight. We found $62K in valid claims never appealed and systematic undercoding on 23% of procedures.
01The Situation
The two dentists had outsourced billing to a third-party service three years earlier. Monthly collection reports showed solid numbers. Nobody had audited the underlying claims. When one dentist attended a dental business seminar and heard about undercoding, she asked us to take a look.
The audit found 184 valid claims denied for technical reasons and never appealed. 122 were still within the appeal window. Beyond denied claims, 23% of procedures were coded at a lower complexity level than performed, a systematic undercoding costing $84,000 per year in valid revenue.
02What We Did
We pulled every claim for three years and matched against ERA remittance advices and the practice management system. Denied claims were categorized by denial reason, dollar amount, and appeal window status. For the 122 claims still within the window, we prepared and filed appeals with supporting documentation. Recovery rate on filed appeals: 79%.
The undercoding issue was fixed by establishing correct coding for the eight most common procedures. Projected annual revenue improvement from correct coding: $84,000.
03Client Impact
$62K in valid claims had expired uncollected because no one checked the denial queue. The audit recovered the money and built a system that prevents the same loss going forward.
Breakdown
| Issue Found | Volume | Dollar Impact | Action Taken | Status |
|---|---|---|---|---|
| Denied claims never appealed | 122 claims | $48,800 | Appeals filed within window | |
| Expired appeal windows | 62 claims | $12,600 | Written off, uncoverable | |
| Undercoded procedures | 23% of cases | $84K annual | Recoding implemented | |
| Secondary insurance missed | 41 patients | $11,000 | Secondary claims filed | |
| TOTAL RECOVERED | — | $62,000+ | All actions taken |
What changed
$62K in Denied Claims Recovered
122 appeals filed. 79% recovery rate. $12,600 written off as time-expired.
Undercoding Fixed on 23% of Procedures
Correct codes for 8 most common procedures. $84K projected annual improvement.
Billing Audit System Built
Monthly audit of denied claims now mandatory. No denied claim goes unreviewed.
Secondary Insurance Billing Implemented
41 dual-coverage patients identified. Secondary claims filed. $11K recovered.
$62K in valid claims had expired uncollected because no one checked the denial queue. The audit recovered the money and built a system that prevents the same loss going forward.
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