The pediatric practice was facing a lot of administrative hurdles and these hurdles were disturbing their billing processes and impacted revenue badly. Pediatric billing requires close coordination between clinical documentation and guidelines of insurances. Our team understands that misalignment in coding and expectation of payers had led to delayed payments, frequent claim denials, and inconsistent cash flow.
Client Profile:
Client Specialty: Pediatrics
State: Washington (WA)
Portals Worked On: Medicare, Medicaid, Fidelis, Availity, UHC
Challenges Identified
A pediatric practice reached out to One O’Seven RCM when they were struggling with revenue that were at just $4,000 per month. Despite seeing a steady flow of patients, the billing cycle was broken. Claims were not being paid on time or at all and there was no clarity on the root causes. The practice was enrolled with major payers including Medicare, Medicaid, Fidelis, UHC, and Availity, but payments remained inconsistent or denied.
After an initial audit of the practice’s billing operations and payer interactions, the following core issues were identified:
1. Taxonomy Errors
The provider’s taxonomy code did not accurately reflect their pediatric specialty, causing frequent claim rejections, especially from Medicaid and Medicare. Payers require precise taxonomy alignment to validate scope of practice and proper reimbursement.
2. Coding Inconsistencies
There were repeated inaccuracies in the use of CPT and ICD-10 codes. Most notably, well-child visits and vaccine administration codes were improperly documented, often missing necessary modifiers. This resulted in denials, partial payments, or downcoded reimbursements.
3. Enrollment Issues
Despite being paneled with major payers, the enrollment status was not properly updated or maintained in several portals. Credentialing gaps caused several claims to be marked as “provider not enrolled,” triggering non-payments. Some enrollments had lapsed without the provider’s knowledge, further disrupting cash flow.
One O’Seven RCM’s Intervention
Taxonomy Correction
Our credentialing team conducted a thorough review of the provider’s NPPES (National Plan and Provider Enumeration System) profile and payer-specific applications. We corrected and updated the taxonomy code to align with the pediatric specialty across all portals particularly Medicare, Medicaid, and UHC.
Coding Review and Training
A certified coding expert from our team performed a 90-day retrospective audit on denied and underpaid claims. After pinpointing common errors, we revised internal coding practices and provided training on proper pediatric-specific coding, including:
- Immunization codes
- Preventive care visits
- Developmental screenings
- Newborn care bundles
Modifiers like 25, 59, and 51 were explained in context and added where necessary to prevent bundling issues.
Enrollment and Portal Management
We reassessed the provider’s status with Fidelis, Availity, UHC, and other major payers. Our enrollment specialists submitted reactivation and update requests, ensured proper linkage to group and individual NPI numbers, and confirmed active status across each payer portal. Delays in initial credentialing submissions were resolved with direct payer communication, especially with Medicaid.
Results Within 6 Months
Within just six months, the practice achieved amazing results:
- Revenue grew from $4,000/month to $35,000/month
- Claim acceptance rate improved by 88%
- Reduction in denial rate by 76%
- Average AR days dropped from 63 to 28 days
- 90%+ first-pass claim resolution rate
Conclusion
Small practices mostly face challenges in their revenue, not because of a lack of patients, but due to some inefficiencies in billing and payer communication. This pediatric practice’s transformation explains about the importance of accurate taxonomy, coding, and enrollment and growth of revenue with these fundamentals.
At One O’Seven RCM, we bring clarity to chaos and ensure that even the smallest practices can achieve financial stability and growth.
