Aug 10, 2025

By: Laurel Jones, MBA, PMP, Six Sigma Black Belt

For: Just Right Business Services, LLC

Overview:

There are usually three primary culprits eating away at your revenue. If not addressed these culprits can cripple your revenue cycle.

Step inside the black box of healthcare billing and uncover why so many revenue cycles grind to a halt when they rely on insurance claims. Here’s the hard truth: healthcare billing is complicated—and every gap in your process bleeds cash. When claims stall or bounce, your revenue cycle stretches, cash flow tightens, and staff morale takes a hit. Three culprits drive most delays: human error, ever-changing codes, and inefficient workflows.

Challenges:

1) Human error → denials and rework.
Incomplete demographics, missing documentation, wrong modifiers, and eligibility missteps trigger costly resubmissions and appeals. Medicare’s latest Fee-for-Service review estimates a 7.66% improper payment rate—billions tied to coding, documentation, and medical-necessity errors that lead to repayment or delayed reimbursement. (CMS) Medical group leaders confirm the pressure: 60% saw denial rates rise year over year in 2024. (MGMA)

2) Code changes and updates → friction at scale.
ICD-10-CM and CPT are not static. New and revised codes—plus shifting guidelines—roll out on set cycles (e.g., ICD-10-CM FY 2025 updates effective Oct 1, 2024) and mid-year adjustments. If your EHR, fee schedules, and provider education don’t keep pace, you invite denials for “invalid code,” “non-covered service,” or “insufficient documentation.” (CMS, American Hospital Association, AHIMA)

3) Process inefficiencies → slow cash, high cost.
Work queues without clear ownership, manual status checks, and weak front-end controls extend days in A/R. MGMA notes denials frequently stem from coding errors, missing information, or payer medical-necessity disputes—all preventable with stronger upstream process discipline. (MGMA) Add prior authorization to the mix and delays compound: 93–94% of physicians report PA delays care, with documented negative impacts on outcomes and productivity. From a business perspective, those delays cascade into postponed services, late claims, and unpredictable revenue. (American Hospital Association)

In the end, billing breakdowns don’t just hit your bottom line—they erode patient trust. Time and again, I’ve heard patients say, “The doctors and nurses were great. The problem was getting in to see the doctor.” Too often, the cause is prior authorization delays or a shortage of needed specialists. Add to that the frustration of payments not being acknowledged, or other human and system errors, and the patient experience takes a hit.

If your revenue cycle is creating barriers to care, it’s time to fix the process before it costs you both patients and profit.

What to do about it (no sugar-coating)

Tighten the front end. Verify eligibility and benefits before service; standardize check-in scripts; require complete orders and documentation. A clean claim starts at registration—not in coding.

Make coding a living process. Align your update cadence to official release cycles; push “what changed” briefs to clinicians; audit notes against LCD/NCD requirements; and reconcile fee schedules in your EHR every cycle. Reference official guidelines at each update window. (CMS, American Hospital Association)

Instrument denial management. Tag denials by root cause (eligibility, coding, documentation, PA). Build weekly dashboards for first-pass yield, denial rate, and appeal turnaround; fix the top two causes before chasing the long tail. MGMA emphasizes analysis first—then targeted prevention. (MGMA)

De-friction prior auth. Centralize PA rules, templates, and payer contacts; capture auth numbers on the encounter; track expirations; escalate systematically. The burden is real, Design around it. (American Hospital Association)

Automate the boring, elevate the critical. Use bots or EDI to post remits, check status, and flag edits; redeploy staff to documentation coaching and complex appeals.

Close the loop with clinicians. Fast feedback on documentation and coding raises first-pass yield and reduces rework. Celebrate wins (e.g., fewer retries, faster pays) to reinforce behavior.

In conclusion, if you’re seeing rising denials, aging A/R, or chronic rework, you don’t have a people problem, you have a process problem. JRBS helps medical practices and payors cut noise, speed reimbursement, and stabilize operations with practical fixes rooted in Six Sigma and real-world RCM.

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