By Lemuel Areglo, CPC | Director of Revenue Cycle Management Services
Key Takeaways
- Unresolved claims, delayed A/R reviews, and outstanding patient balances can significantly impact revenue. By the time these issues become apparent, your practice’s cash flow may already be compromised.
- Many denials can be avoided with proactive measures. Gaps in eligibility, coding mistakes, and incomplete information can be addressed before claims are submitted, provided you have effective verification and scrubbing processes in place.
- Patients who are informed about their financial responsibilities upfront tend to pay more promptly and with fewer disputes. Unexpected bills can lead to dissatisfaction and reduced patient retention.
- Revenue cycle issues develop gradually. By the time they are recognized, the financial impact may already be felt.
This guide addresses the frequent obstacles to effective collections and offers actionable workflows to overcome them. Navigate to the section that resonates with your current challenges — each is crafted to stand independently.
Table of Contents
Understanding Revenue Cycle Challenges in Pulmonology
The core issue: ownership of the process is often unclear.
Front desk staff may assume billing will handle eligibility verification, while billing teams expect clinical documentation to be thorough. This lack of clarity can lead to claims falling through the cracks, resulting in unpleasant surprises when A/R reports are reviewed.
Billing for specialty practices like pulmonology presents unique challenges. Pulmonology billing differs significantly from general practice billing. A billing team that manages multiple specialties may lack the specialized knowledge necessary to identify errors specific to pulmonary care before claims are submitted, leading to compounded issues.
Common issues include:
- Eligibility gaps — Failing to verify insurance before patient visits can result in claims being sent to the wrong payer or outright denials, leading to costly resubmissions.
- Documentation deficiencies — Inadequate clinical notes that do not justify the services rendered will lead to payer rejections, as they do not extend the benefit of the doubt.
- Coding errors — Incorrect CPT or ICD-10 codes can result in underpayment or denial. Pulmonary coding requires specialized knowledge that generalist billers may not possess.
- Lack of follow-up processes — Claims can age without follow-up, risking timely filing and potential loss of revenue.
Establishing a Proactive Denial Management System
Denial management should be viewed as a systematic approach rather than a reactive cleanup task.
Prevent denials before submission
Most denials are preventable. The primary causes — missing information, eligibility issues, and coding errors — can all be identified before claims are submitted.
Verify insurance eligibility prior to each appointment, not just at check-in. Confirm payer details, plan type, copay, deductible status, and prior authorization requirements, and document this information.
Utilize claim scrubbing tools before submission. Your billing software should identify missing modifiers, bundling issues, and frequency limit violations. If it doesn’t, you risk sending out claims that are likely to be denied.
Identify denials immediately
When a denial is received, route it for review on the same day. Each hour it remains unaddressed brings you closer to missing the timely filing deadline. Categorize denials by reason code — eligibility, authorization, coding, documentation, or duplicate — and monitor for patterns. If one provider has a higher denial rate, it may indicate a documentation issue. If a particular payer denies more frequently, it could signal a contractual issue.
Resolve within 48 hours
Aim for a resolution within 48 hours of receiving a denial. If a denial cannot be resolved at the first level, escalate it promptly and ensure it does not remain unresolved. Document the resolution steps for each denial type to streamline the process for future occurrences.
Effective A/R Strategies for Pulmonary Practices
The reality is that merely reviewing A/R on a monthly basis is insufficient. Genuine follow-up should occur weekly, prioritizing claims based on age and dollar amount.
The likelihood of collecting on claims decreases significantly as they age. Claims under 30 days have a collection rate above 95%, while those over 120 days may drop below 50%. Each week of inaction moves you further down this curve.
A straightforward weekly routine:
- Day 1 — Review claims aged 0–30 days. Confirm receipt and ensure claims are being processed.
- Day 2 — Address claims aged 31–60 days. Contact payers regarding any claims with no activity. Document every interaction.
- Day 3 — Escalate claims aged 61–90 days. These are nearing critical age.
- Day 4 — Take aggressive action on claims over 90 days. Check for timely filing deadlines. Do not allow these claims to languish.
- Day 5 — Follow up on patient balances and initiate discussions about payment plans.
KPIs to track:
Metric
Target
Days in A/R
Under 35
A/R over 90 days
Under 15% of total
Clean claim rate
95%+
Denial rate
Under 5%
What's Slowing Down Your Claims
Inefficiencies in billing often stem from two main issues: role confusion and intake errors.
When one individual manages registration, eligibility, charge entry, and follow-up, accountability diminishes. It is essential to separate front-end tasks (registration, eligibility, authorization) from back-end tasks (coding, billing, A/R management). This separation is critical, even in smaller practices.
Another significant issue is inaccurate data collected during intake. Incorrect insurance IDs, demographic details, and missing authorization numbers can lead to claim failures later in the process, especially when the visit is weeks old and documentation is no longer fresh.
Advanced EHR vendors provide AI-powered intake platforms that enhance intake accuracy and reduce front desk bottlenecks, ultimately minimizing data entry errors that can delay claims processing.
Verify before the appointment:
- Patient demographics
- Active insurance coverage and effective dates
- Copay, deductible, coinsurance status
- Prior authorization (if required)
- Estimated patient responsibility communicated to the patient
Submit claims daily rather than in weekly batches. Daily submissions allow errors to be identified while the encounter is still fresh and catch clearinghouse rejections early — a rejected claim will not be in the payer’s queue at all.
Enhancing Patient Communication for Better Collections
With the rise of high-deductible plans, patient financial responsibility has increased significantly. Collecting these amounts requires a different strategy than collecting from payers.
The most effective strategy is not merely about statement design; it lies in the conversations held prior to the visit. Patients who understand their financial obligations beforehand tend to pay more quickly and with fewer complaints. Conversely, those who receive unexpected bills are less likely to pay and may not return for future visits.
Collect copays at check-in. Send statements within a week of claim adjudication. Facilitate easy payment options online, via phone, text-to-pay, and offer payment plans for larger balances. Patients are more likely to utilize options when they are available.
A basic outreach cadence:
- Statement sent on day 0 (post-adjudication)
- Reminder sent on day 30 (statement + email or text)
- Phone call made on day 45
- Final notice issued on day 60 with a payment plan offer
- Consider collections on day 90
Document every attempt. A thorough paper trail is crucial if an account is sent to collections.
Quick-Reference Checklists
Pre-visit
- Demographics verified
- Eligibility confirmed
- Benefits documented
- Authorization obtained (if required)
- Patient informed of estimated cost
Claim submission
- All fields complete
- Diagnosis codes support medical necessity
- Procedure codes match documentation
- Modifiers applied correctly
- Claim scrubbed
Denial management
- Denial identified within 24 hours
- Reason code categorized
- Resolution initiated within 48 hours
- Appeal filed (if applicable)
- Root cause logged for pattern tracking
Patient collections
- Copay collected at time of service
- Statement sent within 7 days of adjudication
- 30-day reminder sent
- 45-day phone outreach attempted
- Payment plan offered before day 60
The Integration Problem Most Practices Ignore
Many billing inefficiencies arise from poor handoffs rather than personnel issues. When clinical documentation, practice management, and billing operate in separate systems, data must be re-entered, leading to errors and missed charges.
WRS Health integrates all three functions within a single platform. When a provider completes an encounter, billing processes begin immediately with complete clinical context — eliminating the need for exports, manual entries, and gaps in information. For practices seeking further efficiency, Pulmonology-Cloud Billing Services provides dedicated specialists who understand your specialty, adhere to a weekly A/R cadence, and identify denial patterns before they escalate into revenue issues.
If your in-house billing is facing challenges with volume, increasing denial rates, or staff turnover affecting continuity, it may be time to consider outsourcing as a viable solution.
The workflows outlined above are effective. The question remains whether your current setup can support them. If not, it may be time for a candid evaluation.
Talk to our billing team for a FREE billing analysis.
Lemuel Areglo, CPC
is the Director of Revenue Cycle Management Services at WRS Health, bringing nearly 15 years of experience leading medical billing, coding, credentialing, and revenue cycle operations across the healthcare industry. Lemuel’s expertise spans the full revenue cycle, including claims management, denial resolution, payment posting, accounts receivable, and practice operations. He has extensive experience supporting specialties including pulmonology, psychiatry, physical therapy, pain management, internal medicine, orthopedic surgery, speech therapy, and sleep medicine.
