By Lemuel Areglo, CPC | Director of Revenue Cycle Management Services
Key Takeaways
- Unresolved denials, infrequent A/R assessments, and aging patient balances can severely impact cash flow. By the time these issues become apparent, financial health may already be compromised.
- Many denials are avoidable. Gaps in eligibility, coding mistakes, and incomplete information can be addressed prior to claim submission with proper verification and scrubbing protocols.
- Patients informed of their financial responsibilities upfront tend to pay more promptly and with fewer disputes. Conversely, unexpected bills can lead to dissatisfaction and reduced return visits.
- Revenue cycle issues develop gradually. Often, by the time they are recognized, cash flow has already been affected.
This guide addresses the prevalent reasons for collection delays and offers actionable workflows to resolve them. Navigate to the section that currently poses the greatest challenge — each is crafted to function independently.
Table of Contents
Understanding Common Billing Challenges in Gastroenterology
The core issue: lack of ownership across the revenue cycle.
Front desk staff often assume that billing will handle eligibility issues, while billing teams expect clinical documentation to be thorough. This disconnect can lead to claims being overlooked, resulting in poor A/R outcomes.
Gastroenterology practices face unique challenges. Gastroenterology billing differs significantly from billing practices in other specialties like orthopedics or cardiology. A generalist billing team may lack the specialized knowledge needed to identify gastroenterology-specific errors before claims are submitted, leading to compounded issues.
Key contributors to billing challenges:
- Eligibility issues — Failing to verify insurance prior to the appointment can result in claims being sent to incorrect payers or outright denials, leading to costly resubmissions.
- Documentation gaps — 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 inaccuracies — Incorrect CPT or ICD-10 codes can result in underpayment or denial. Gastroenterology coding requires specialized knowledge that generalist billers may not possess.
- Lack of follow-up — Claims can age without any follow-up, risking timely filing and making them unrecoverable.
Developing a Denial Management System
Denial management should be viewed as a proactive system rather than a reactive cleanup task, encompassing three key components: prevention, identification, and resolution.
Preventing Denials Before Submission
Most denials can be avoided. The primary causes — missing information, eligibility issues, and coding errors — can be identified before claims are submitted. Ensure insurance eligibility is verified before each appointment, not just at check-in. Confirm payer details, plan type, copay, deductible status, and any prior authorization requirements, and document this information thoroughly.
Implement claim scrubbing prior to submission. Your billing software should identify missing modifiers, bundling issues, and frequency limit violations. If it fails to do so, you risk sending out claims that are likely to be denied.
Identifying Denials Promptly
When a denial occurs, it should be routed for review on the same day. Each hour that it remains unaddressed brings you closer to missing timely filing deadlines. Categorize denials by reason code — eligibility, authorization, coding, documentation, or duplicate — and monitor for patterns. If one provider has a higher denial rate than others, it may indicate a documentation issue. If a particular payer has a higher denial rate, it could signal a contract issue.
Resolving Denials Within 48 Hours
Aim to resolve denials within 48 hours of receipt. If a denial cannot be addressed at the first level, escalate it promptly and avoid letting it linger. Document the resolution steps for each denial type to ensure staff do not have to reinvent the process each time.
Effective A/R Follow-Up Strategies
The reality is that merely reviewing A/R once a month is insufficient; it is merely documentation. Genuine follow-up should occur weekly, prioritizing claims based on age and dollar amount.
Collection rates decline sharply as claims age. Claims under 30 days have a collection rate exceeding 95%, while those over 120 days may drop below 50%. Every week of inaction reduces your chances of recovery.
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 for any claims without 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 go unaddressed.
- 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%
Identifying Bottlenecks in Claims Processing
Inefficiencies in billing often stem from role confusion or errors during intake.
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 crucial, even in smaller practices.
Another significant issue is poor data collection at intake. Incorrect insurance IDs, demographic errors, 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 systems provide AI-powered intake platforms that enhance intake accuracy and alleviate front desk bottlenecks, ultimately reducing the incidence of data errors that can delay claims processing.
Verify information prior to the appointment:
- Patient demographics
- Active insurance coverage and effective dates
- Copay, deductible, and coinsurance status
- Prior authorization (if necessary)
- 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 they also catch clearinghouse rejections early — a rejected claim will not be in the payer’s queue at all.
Strategies for Patient Collections
With the increase in high-deductible plans, patient financial responsibility has grown significantly. Collecting these amounts requires a different strategy compared to collecting from payers.
The most effective strategy is not merely about statement design; it lies in the conversation held prior to the visit. Patients who are made aware of their financial responsibilities beforehand tend to pay more quickly and with fewer complaints. In contrast, those who receive unexpected bills are less likely to pay and may not return.
Collect copays at check-in. Send statements within a week of claim adjudication. Provide convenient payment options such as online payments, phone payments, text-to-pay, and payment plans for larger balances. Patients who have multiple payment options are more likely to utilize them.
A basic outreach schedule:
- Statement sent on day 0 (post-adjudication)
- Reminder sent on day 30 (statement + email or text)
- Phone call made on day 45
- Final notice sent on day 60 with a payment plan offer
- Consider collections on day 90
Document every attempt. A thorough paper trail is essential if an account eventually goes to collections.
Quick-Reference Checklists
Pre-visit
- Demographics verified
- Eligibility confirmed
- Benefits documented
- Authorization obtained (if required)
- Patient informed of estimated costs
Claim submission
- All fields completed
- Diagnosis codes support medical necessity
- Procedure codes align with documentation
- Modifiers applied accurately
- Claim scrubbed thoroughly
Denial management
- Denial identified within 24 hours
- Reason code categorized
- Resolution initiated within 48 hours
- Appeal filed (if applicable)
- Root cause documented for tracking patterns
Patient collections
- Copay collected at time of service
- Statement sent within 7 days of adjudication
- 30-day reminder dispatched
- 45-day phone outreach attempted
- Payment plan offered before day 60
The Integration Challenge Many Practices Overlook
A significant portion of billing inefficiencies arises from handoff issues rather than personnel problems. When clinical documentation, practice management, and billing operate in separate systems, data is re-entered, errors are introduced, and charges may be overlooked.
Gastroenterology-Cloud integrates all three components into a single platform. When a provider completes an encounter, billing processes begin immediately with complete clinical context — no need for exports, manual entries, or data gaps. For practices seeking further efficiency, Gastroenterology-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 team is struggling 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 critical question is whether your current setup can support them. If not, it may warrant a thorough 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 gastroenterology, psychiatry, physical therapy, pain management, internal medicine, orthopedic surgery, speech therapy, and sleep medicine.
