1. Insurance eligibility & benefits are verified before every visit
Not checking coverage up front is the #1 source of denials. Verify eligibility, plan status, and benefits before the patient is seen.
2. Prior authorizations are obtained and tracked
Missed or expired auths cause hard denials that are often non-appealable. Track every required auth to expiration.
3. Claims are scrubbed before submission
Sending unscrubbed claims means rejections and rework. A pre-submission scrub catches errors before the payer does.
4. Denials are worked within each payer’s appeal window
Every payer has a deadline. Denials not appealed in time become permanently lost revenue.
5. Denial reasons are tracked for patterns
If you don’t log why claims deny, the same denials keep happening. Trend them and fix the root cause.
6. Aging A/R over 90 days is actively followed up
Old A/R quietly turns into write-offs. Someone must work the 90+ day bucket every week.
7. Payments are checked against contracted rates
Payers underpay more often than practices realize. If no one compares paid vs. contracted, the underpayment is never recovered.
8. Coding is current for your specialty (CPT/ICD-10)
Outdated or non-specific coding leads to down-coding, denials, and compliance risk. Keep coding current to your specialty.
9. Patient / self-pay balances are collected consistently
Uncollected patient balances become bad debt. A clear, consistent collections process protects this revenue.
10. Payments are posted and reconciled accurately
Posting errors hide underpayments and distort your numbers. Reconcile payments to remittances every cycle.
11. Provider credentialing & payer enrollment are current
If a provider isn’t actively enrolled with a payer, those claims deny. Keep credentialing and enrollment from lapsing.
12. You review RCM KPIs monthly
If you don’t track clean-claim rate, days in A/R, denial rate, and net collection rate, you can’t see the leak. Review them every month.