No single article could possibly cover all the possible problems that could be encountered in your practice. However, it’s always a good idea to pay attention to problems that others are encountering to try and keep them from happening to you. The skills that make an individual a good provider are not necessarily the same skills that make a practice profitable. There are several things that practices may be overlooking which can hurt their bottom line.

Not Knowing Payer Guidelines

The problem with not knowing a payer’s guidelines is that in this age of recoupments and audits, what you don’t know can hurt your practice. it is critical to know a payer’s rules. If you don’t follow their rules, they will take the money back — period.

Your organization needs to have a policy in place where someone is assigned to routinely check the payer guidelines for those payers that are a large percentage of the claims your practice submits. We suggest subscribing to their newsletters because they typically contain information about updates to their policies. There’s no need to subscribe to every payer’s newsletter, but be sure you are receiving those that you frequently bill. For those that you use less frequently, it would be a good idea to check their website if a patient who has a policy with them has set up an appointment.

If the payer doesn’t have a newsletter, check their website a minimum of once a year (6 months is better). Sometimes, if you are not a contracted provider, you don’t have access to a payer’s policy information. And even if you are a contract provider, the information may be hard to find. If you are having a hard time, contact the provider relations department and ask for their policies on those services that are most frequently billed.

Tip: FindACode makes it easy to find associated Medicare NCDs and LCDs. Subscribers can see that information at the code level. They also have an add-on option for commercial payer policies (e.g., UnitedHealthcare).

Not Reviewing Contracts

Many payers have “evergreen” clauses in their contracts. While it’s nice not to have to review contracts every single year, not knowing what has changed can hurt you. For example, we heard about a provider that got stuck on a very old fee schedule and was getting paid $10 for a $100 service. That’s a pretty big hit. Another problem is that the payer may stop paying for services that they used to pay for. 

Be sure that you have all your contracts in a single, secure place. Implement a program to track the renewal dates. Three months BEFORE the contract is set to renew, it is critical to carefully review the contract for any changes. Be sure that it is still cost effective to continue to participate (see the “Not Reviewing and/or Refuting Clearinghouse Reports” section below). If it isn’t, then cancel the contract before it automatically renews.

If you can’t find your contracts, call the provider relations department and ask for a copy of your contracts. If you encounter problems getting a copy, having an attorney make the request for you will typically speed things up.

Note: We have heard that sometimes simply the act of submitting a claim to a payer will automatically enter you into a contract with a payer. Before submitting a claim to a new payer, check their website or contact their provider relations department!

Not Checking Eligibility

Eligibility has been cited as the number one problem of claim denials (see “Denial Management is Key to Profitability” in References below). Every practice should ensure that they have official policies and procedures related to checking eligibility. Eligibility can change frequently. Just because a patient was covered last month does not mean that they have the same coverage today.

Not Paying Attention to EMR Issues

While no one is denying that there are benefits for the use of Electronic Medical Records (EMRs), there are still some issues that continue to plague healthcare provider documentation. The ability to carry forward and to copy and paste information is a two-edged sword. A fact sheet by CMS (see References below) states:

“... features like auto-fill and auto-prompts can facilitate and improve provider documentation, but they can also be misused. The medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter. Simply changing the date on the EHR without reflecting what occurred during the actual visit is not acceptable.”

One idea for helping to ensure that you are seeing what you have changed is to use a different font. This can help attending physicians to easily identify that they have reviewed the record. It enables all providers to see what is different between patient encounters.

Exercise caution when reporting “Within Normal Limits”. EMRs tend to give the ‘appearance’ that something is complete, when they actually are deficient. For example, auditors have stated that it isn’t uncommon to see a ‘within normal limits’ statement in an area of a patient complaint without any supporting evidence. While it is true that the area of the patient complaint may be normal, you MUST document that fact. Instead of just saying WNL, explicitly state that you have examined the patient’s complaint area and found it to be within normal limits.

Not Sufficiently Training Employees

According to one attorney, healthcare is one of the most highly governed businesses. You are right up there with nuclear energy. There are so many rules and regulations that it is easy to get overwhelmed and miss things. Many payer contracts have been adding compliance clauses. You must have an active compliance program in your practice. The key word in that sentence is ‘active’. It is not enough to have a program on paper. A key component of “active” is training that happens on a regular basis. The time frame for training can vary depending on the compliance program. Remember that compliance is more than just HIPAA which has its own training requirements. There is also OIG, Occupational Safety and Health Administration (OSHA), State Departments of Labor and Industries, and other programs to consider.

Ongoing training is more than just satisfying compliance laws. There’s a reason why professional licenses require training — it helps you be a better professional. Poorly trained staff can create a myriad of problems. Training also includes topics such as billing, documentation, and practice management. It is one of the best ways to help your practice;

  • Avoid claim denials
  • Continue to grow
  • Help employees feel confident
  • Help employees perform better

Bottom line: Well trained employees help your practice

Not Reviewing and/or Refuting Clearinghouse Reports 

What you submit to your clearinghouse needs to be regularly checked to make sure that what you thought was submitted is what was actually billed. That’s YOUR responsibility — not the clearinghouse’s. Ask the billing company for reports to review. If you see something ‘off,’ be sure to get more detailed information. Payers don’t care if an error occurred with your billing company. You are ultimately responsible for that claim. Repeated bad claims can put you under pre-payment review status or even exclusion from their program.

Carefully review claim adjustment codes. Ask your biller/billing company to give you a list of all the adjustment codes and then look at those codes in your month end report. You need to keep track of individual types of adjustment codes. Be sure that each payer has their own unique adjustment code so you can see which payers you have to write off more often. It might not be worth maintaining a contract with that payer if there are significant write-offs.

As a reminder, if you are not a contracted provider with that payer, you do not have to write off the unallowed amounts. Too many providers are writing off amounts that they are not required to. Some consultants suggest that even small balance write-offs should have a two-person signoff before an adjustment is made. 

Also, be sure that you review the universal denial codes (e.g., reason/remark codes). Why was the claim denied? What was wrong with the claim? Was information missing and if so, from whom? Don’t assume that just because a claim wasn’t paid that you can’t appeal or get appropriate payment. If you see a lot of denials, then perhaps it’s time to have additional training on denial management (see “Denial Management is Key to Profitability” in References below).

Alert: Some states require billing companies to be registered with the state (e.g., Texas). Find out what is required for your state and be sure that you are meeting state law.


It’s the little things that can cause problems in a practice. Taking time to address these common problem areas can help to ensure that your organization remains profitable and stays out of trouble.