Keeping the Wheels On:
Where Things Go Wrong
in Medical Billing

optimal medical billing

Keeping the Wheels On:

Where Things Go Wrong in Medical Billing

March/April 2022 RBMA Bulletin

Professional athletic teams run drills at the beginning of the season before they begin to refine complex plays.  Musicians practice scales and technical exercises.  Competitors in individual sports incorporate routines to maintain strength and mobility.  It shows no matter what we know or how accomplished we have become in our careers, it is good to occasionally drill the basics—and that includes knowledge basics if we’re seeking optimal performance in our practices.

Seeking Optimal Performance

I’ve often joked that a practice manager is only as good as the last physician bonus.  There is truth to that fact, although you and your group will likely ride through some challenging financial times together and hopefully all will remain realistic about what is under your control.

On the other hand, consultants are usually called in when physicians are frustrated with revenue, usually with the comment, “I’m working harder than ever and making less money.  Can you find out what’s going on?”

Predictable Revenue = Happiness Reigns

While each individual billing process step is readily definable, in total they are also fraught with exceptions and intertwined so an error or problem in one area has the potential to impact a chain of events.  When it all works well, the little hiccups experienced each day are handled promptly and the process flows as it should.  This means the revenue comes in predictably and happiness reigns. (Note: this does not include the impact of regulatory and policy changes, representing monkey wrenches to mess things up).

Address Problems Quickly and Effectively

With that said, there are certain process junctures where problems are more likely to occur and it’s a good basic drill to checklist through them when things seem to be going sideways.  These things can happen to both inhouse operations and outsourced billing companies

The “thing” may well be out of their control, so the secret is how quickly and effectively they address the problem when it happens.  What follows is not a comprehensive list but represents common pain points. 

Common Medical Billing Pain Points

Payment Posting

Electronic Payment Processing and Posting

Electronic payment processing and posting drastically shortened the gap between claims submission and money in the bank.  With that said, the money may be in the bank but still not posted to the billing system and that is problematic.  When payment posting becomes backlogged, secondary claims are not released nor are patient statements—and internal financial reporting is impacted as well.

Automated Claim Refiling

What else?  If the billing system is set up to automatically refile claims after a certain interval if the system sees payment has not been made (due to the posting delay), the refile will probably be denied as a duplicate.  

The problem in radiology lies in the fact that will not be an isolated claim, but probably hundreds or thousands of them.  This in turn can plop an unnecessary stack of denials on top of the folks handling A/R follow-up and has them spinning their wheels on claims that have already been paid.  If the delay continues, additional refiles occur and the problem can quickly escalate into an A/R management nightmare.

Is this a rare problem?  Not really, so it’s worth monitoring the time between claims submission and payment posting (and whether automatic refiles are causing other backlogs and may need to be turned off).

A periodic payment lag can happen to any practice for a multiple of reasons and will require mobilization of resources to tidy up.  At the same time, it should not be a chronic problem.      

A/R Follow-up

We know “days in A/R” are like a golf score—lower is better.  We also know the longer a charge sits in the accounts receivable, the more difficult it will be to collect so we conduct the delicate dance of A/R monitoring and management

It is complicated by the fact there are two ultimate ways to reduce the A/R: 

  1. Collect the money (which can include successfully appealing a denied claim)
  2. Adjust/write off the charge

There will be legitimate write-offs and adjustments and they are to be expected.  (See the RBMA Accounts Receivable Standard Definitions and Formulas for more information on this.)  As claims sit in the A/R awaiting follow-up, appeal and/or other activity (including write-offs), the total A/R can build.

A/R Creep

One of the indicators of trouble in A/R follow-up:  exam volumes and charges remain steady but the A/R increases.

This is A/R creep and some of the reasons it can occur are:

  • Delays credentialing new physicians, which can also result in denials for timely filing or “provider not eligible at time of service”

  • Build-up of claims from less efficient payors (for example, Workers Compensation, motor vehicle accidents, prison systems, uninsured/undocumented patients, Indian Health Services)

  • Build-up of patient responsibility/private pay accounts

  • Other problems that can for example, lead to bulk appeals

Part of monitoring the A/R includes reviewing write-offs and adjustments for unusual activity and that would include the use of non-standard adjustment categories.  You should be able to receive clear communication regarding any adjustment questions.

Missing Charges

Virtually all hospital-based radiologists are convinced they are missing charges from the hospital, that they are reading more cases than are being billed.  They probably are but unless your organization has an auditing mechanism in place, you will not know the impact.  And unless that process is automated, it is extremely cumbersome to manage and in that case, missing charges will remain an unvalidated hunch.

Most groups receive demographic and radiology report files electronically and there are matching criteria in the billing system to establish a billable charge from those files. 

The first problem resolution trap, then, is to determine whether one of those files is missing and today’s billing systems should be able to report when you receive:

  • A demographic file but no matching radiology report (for example, when a case may be held up for comparison images and dictated later)

  • A radiology report but no matching demographics

Tracking down and reconciling these files is part of ordinary processes so our greater concern is the failure to receive any information from the facility and not having flags to identify the problem. 

Why does information go missing?

While file transfers have been one of the biggest (and usually dependable) game changers in radiology billing, the process is not without flaws and most of them seem to occur on the hospital side.  This can manifest in several ways: 

  • Failed File Transfer

    Failure to receive a file at all should quickly be detectable by the practice.  Resolution of the problem varies from “quick” to days and in rare cases, weeks, depending on how the failure occurred. 

    In real life, the worst case I’ve encountered involved working with a hospital that said they were unable to reconstruct a week of failed files, took a “sorry about that” stance and did very little to resolve the issue until bigger guns from the hospital C-suite became involved.  It was a painful delay at best.

  • Partial File Failure

    In some ways a partial file failure can be worse because it is more difficult to detect.  This is where audits are invaluable, especially in the event random patient files are omitted from the transfer, rather than a transmission failing partway through the process. 

    Is this a big deal?  In the retrospective audit of a smaller hospital, we found up to 30% of the day’s patients were missing but on a sporadic basis.  In other words, the omissions did not occur regularly or in a recognizable pattern, so the issue was difficult to both detect and resolve with the hospital IT department.  Over the course of a year, it represented a sizeable amount of revenue to the practice. 

  • More About Audits

    If your practice utilizes one of the newer billing software options, you will obviously be notified when you have a partial billing file (demographics without reports or reports without demos). 

    However, an audit of daily hospital logs compared to billing system activity is the most reliable way to ride herd on missing charges.  Manually reviewing logs is not practical for even small hospital locations but organizations have been able to program the task, so it is worth asking the following:

    1. Are charge capture audits currently conducted?
    2. If so, how often is this completed?

    Again, there can be evidence of lagged charges each day, so charge capture tasks are impacted if, for example, the radiologist is waiting for comparison images.  An audit will account for these delays.


The process functions discussed are by no means comprehensive and there are indeed other areas where the wheels can fall off but tightening down these areas can make a difference in overall financial performance.  It can be the difference between an underperforming practice and a financially healthy one.

headshot of Pat Kroken Director of Education and Corporate communications, MSN Healthcare Solutions

Patricia Kroken, FACMPE, CRA, FRBMA,
has an extensive background in radiology practice management and directs education and corporate communications for MSN Healthcare Solutions

She worked as a consultant for radiology practices, billing companies, software developers, and hospital radiology departments for 20 years before joining MSN.

She is a regular contributor to the RBMA Bulletin and a frequent speaker on topics related to radiology practice management. 
Pat can be reached at
or 505-856-6128