Practice type: Interventional pain management Location: Wyoming Practice size: 2 physicians, 1 nurse practitioner, 3 clinical support staff Procedures performed: Epidural steroid injections, facet injections, radiofrequency ablation, spinal cord stimulator trials and implants, nerve blocks, trigger point injections Payer mix: 42% Medicare, 38% commercial (BCBS of Wyoming, Cigna, UHC), 12% Medicare Advantage, 8% Workers’ Compensation
Background
When this practice first reached out to Malakos Healthcare Solutions in early 2025, the conversation started the way it often does not with a billing emergency, but with a quiet, growing frustration.
The practice had been operating for six years. Both physicians were experienced interventionalists with strong patient volume and a referral network that kept the schedule full. By any clinical measure, they were running a successful practice.
But the billing side of the operation told a different story.
The practice had been working with a regional billing company for four years. On the surface, things seemed functional claims were going out, payments were coming in, and the monthly deposit amounts were consistent enough that no one asked too many questions. The problem, as we discovered during the initial audit, was that “consistent” and “correct” are not the same thing.
“We assumed if the money kept coming in, the billing was working,” the practice manager told us during our first call. “We didn’t realize how much we were leaving on the table until someone actually looked.”
The Initial Audit – What We Found
Before taking over any billing function, Malakos conducts a free revenue cycle audit. For this practice, the audit covered six months of claims data, three months of ERA and EOB records, the full AR aging report, and a sample of thirty procedure notes reviewed against the corresponding claims.
What we found was a billing operation that wasn’t failing in any dramatic way. It was failing quietly in a dozen small ways that each seemed minor in isolation but added up to a significant annual revenue gap.
Finding 1 – Imaging Guidance Codes Billed on Less Than Half of Qualifying Procedures
Of the forty-two fluoroscopy-guided procedures in the sample claim review, imaging guidance (CPT 77003) had been billed on nineteen. The other twenty-three procedures had either not had the guidance code entered on the charge ticket, or the billing team had removed it during claim scrubbing because they couldn’t confirm the documentation requirements were met.
The result was that the practice was collecting imaging guidance reimbursement on roughly 45% of the procedures that qualified for it. At an average of $85 per procedure in Medicare allowable and higher amounts under commercial contracts, the missed billing on imaging guidance alone was running approximately $28,000 per year.
Finding 2 – ESI Approach Codes Inconsistently Applied
Of the thirty procedure notes reviewed, eleven documented a transforaminal approach — but seven of those eleven had been billed under the interlaminar code (CPT 62323 instead of CPT 64483). The billing team had been defaulting to 62323 for lumbar epidurals across the board, regardless of the approach documented in the note.
This created two problems simultaneously. For the claims billed under the wrong code, the reimbursement was lower than what the transforaminal approach warranted. And the medical record vs. claim discrepancy procedure note documenting transforaminal, claim billing interlaminar was an audit flag on every one of those claims.
Finding 3 – RFA Claims Had a 67% Prior Authorization Denial Rate
The practice was performing radiofrequency ablation procedures on an average of eight to ten patients per month. Of the twenty-four RFA authorization requests submitted in the six-month audit period, sixteen had been denied on first submission.
The denial reason in all sixteen cases was the same: insufficient documentation of prior diagnostic medial branch block response. The MBB procedure notes existed in the chart for every one of these patients. They simply hadn’t been included in the authorization package. The billing team was submitting authorization requests with the procedure date, the diagnosis codes, and the CPT codes but not the supporting clinical documentation that most commercial payers require to approve RFA.
Of the sixteen initial denials, eleven were eventually approved after the documentation was resubmitted. Five were not recovered. Beyond the five permanently lost authorizations, the average delay between initial denial and eventual approval was 31 days meaning RFA procedures that should have been scheduled promptly were delayed by over a month while the authorization process churned.
Finding 4 – Multiple Procedure Reductions Applied Above Contracted Rate
The practice’s top two commercial payers BCBS of Wyoming and Cigna both had contracts specifying a 50% reduction on secondary procedures when multiple procedures were billed in the same session. A review of six months of ERA data showed that BCBS was applying a 50% reduction correctly. Cigna, however, was applying a 60% reduction on secondary procedures 10 percentage points above the contracted rate.
Because no one was reconciling ERA payments against contracted fee schedules, this discrepancy had been accepted and written off as a standard contractual adjustment for an unknown period of time. Conservative calculation based on the six-month review suggested the overapplied reduction had been costing the practice approximately $1,800 per month $21,600 per year in underpayments that were being silently written off.
Finding 5 – AR Aging Was Severely Skewed Toward High-Value Claims
The AR aging report showed $287,000 in outstanding balances at the time of the audit. Of that total:
- $41,000 was in the 0–30 day bucket – normal pending adjudication
- $38,000 was in the 31–60 day bucket – starting to require follow-up
- $52,000 was in the 61–90 day bucket – requiring active escalation
- $71,000 was in the 91–120 day bucket – at or approaching timely filing risk
- $85,000 was in the 120+ day bucket – critically aged, some likely unrecoverable
More concerning than the total dollar amount was the composition of the 91–120 and 120+ buckets. The vast majority of the high-aged AR was made up of high-value claims SCS procedure claims, multi-procedure sessions, and RFA claims that had been denied and not appealed, or were stuck in authorization disputes that had never been escalated.
The previous billing company had been following up on volume working the largest number of claims rather than value. Low-dollar office visit claims in the 60-day bucket were getting follow-up attention. $8,000 SCS claims in the 120-day bucket were not.
Finding 6 – E/M Levels Consistently Below What Documentation Supported
A review of established patient office visit coding showed that 94% of established patient visits had been billed at 99213 regardless of visit complexity. Chart review of a random sample of twenty established patient visits showed that fourteen of them documented complexity that supported 99214 under 2021 AMA guidelines: multiple chronic pain conditions managed simultaneously, medication adjustments with monitoring requirements, outside record review, and care coordination with referring physicians.
The difference between 99213 and 99214 under Medicare is approximately $42 per visit. With approximately 180 established patient visits per month, the undercoding on E/M visits alone was running $7,560 per month $90,720 per year in uncaptured revenue on visits the practice was already delivering and already documenting correctly.
Audit Summary
By the end of the audit, we had identified six specific, quantifiable revenue gaps:
| Revenue Gap | Annual Estimated Impact |
|---|---|
| Missed imaging guidance billing | $28,000 |
| ESI approach code errors | $18,400 |
| RFA authorization failures (lost + delayed) | $31,200 |
| Cigna multiple procedure reduction underpayments | $21,600 |
| High-value AR not pursued estimated write-off | $47,000 |
| E/M undercoding (99213 vs 99214) | $90,720 |
| Total identified revenue gap | $236,920 |
We presented these findings to the practice in a meeting with both physicians and the practice manager. The response was immediate.
“The E/M number was the one that hit hardest,” one of the physicians said. “We were documenting everything correctly. The complexity was there. We just weren’t getting credit for it.”
The practice signed with Malakos the following week.
The Transition – What the First 30 Days Looked Like
Onboarding took eleven business days. During that period, Malakos worked in parallel with the existing billing company reviewing active authorizations, assessing which AR items were still within appeal and timely filing windows, and configuring the practice’s existing EHR and practice management system for our billing workflow.
The existing billing company was managing claims in the practice’s AdvancedMD system. We continued working within AdvancedMD no platform migration, no workflow disruption, no gap in claim submission.
The AR backlog was the first priority. Of the $156,000 in 61+ day AR at the time of transition:
- $38,000 was identified as still within commercial payer appeal windows and immediately queued for formal appeal
- $29,000 was within timely filing protection windows under payer error exceptions and resubmitted with documentation
- $22,000 was in Cigna underpayment disputes formal underpayment appeals filed within the first week
- $67,000 was in the 120+ bucket individually reviewed, with $41,000 determined recoverable and pursued, $26,000 confirmed as beyond recovery and written off with documented rationale
Within 30 days of transition, $88,000 in previously unworked AR had been actively engaged appeals filed, resubmissions processed, underpayment disputes opened.
The Results – 90 Days After Transition
At the 90-day mark, we conducted a formal performance review with the practice. Here is what the numbers showed compared to the pre-Malakos baseline:
Denial Rate
Before Malakos: 18.3% overall denial rate across all claim types 90 days after: 7.1% overall denial rate
The primary drivers of the improvement were the pre-submission coding review catching approach code errors before submission, complete authorization packages reducing RFA and SCS first-submission denials, and correct modifier application eliminating a category of bundling denials that had been recurring consistently.
Imaging Guidance Capture Rate
Before Malakos: 45% of qualifying procedures billed with imaging guidance 90 days after: 97% of qualifying procedures billed with imaging guidance
The 3% that remained unbilled were cases where procedure note review identified documentation gaps missing permanent image record notation or absent interpretation report that we flagged for clinical team correction before billing. Rather than billing incorrectly and creating audit exposure, we communicated the documentation gap and billed once it was corrected.
RFA Prior Authorization First-Pass Approval Rate
Before Malakos: 33% first-pass approval rate (16 denied of 24 submitted) 90 days after: 81% first-pass approval rate
The change was entirely documentation-driven. The same procedures, the same patients, the same clinical criteria the difference was that every RFA authorization request now went out with the complete diagnostic MBB documentation package. The procedures that had been getting denied for “insufficient documentation” were approved on first submission when the documentation was actually included.
The three cases that were denied in the first 90 days down from sixteen in the prior six months were pursued through peer-to-peer review. Two were overturned. One remained denied after peer-to-peer and was appealed in writing. That appeal was pending at the 90-day review.
E/M Code Distribution
Before Malakos: 94% of established patient visits billed at 99213 90 days after: 31% at 99213, 61% at 99214, 8% at 99215
Every E/M level change was supported by specific documentation in the corresponding chart note. We provided the practice manager with a one-page documentation guide showing the specific elements that support 99214 vs. 99213 under 2021 AMA guidelines — not to change clinical practice, but to ensure the documentation reflected the complexity of care that was already being delivered.
Days in AR
Before Malakos: 58 days average 90 days after: 39 days average
The 19-day improvement in days-in-AR was driven by two changes: faster submission (charges entered and claims submitted same-week rather than 7-10 day lag under previous billing company) and structured value-weighted AR follow-up that moved high-dollar claims through adjudication faster.
Cigna Underpayment Recovery
Of the $22,000 in Cigna multiple procedure reduction underpayments identified during the audit, $18,400 was recovered through formal underpayment disputes filed in the first two weeks of the engagement. Cigna acknowledged the contract rate discrepancy and issued corrected payments within 45 days of the dispute being filed. The remaining $3,600 involved claims outside the payer’s dispute window and was documented as unrecoverable.
Going forward, every Cigna ERA is reconciled against the contracted 50% reduction rate at payment posting. Overapplied reductions are flagged and disputed within five business days of the remittance.
The Results – 12 Months After Transition
At the one-year mark, the practice’s revenue cycle performance had stabilized at a level significantly above the pre-Malakos baseline. The annualized revenue comparison told the full story:
| Metric | Pre-Malakos (annualized) | 12 months with Malakos |
|---|---|---|
| Total net collections | $1,420,000 | $1,761,000 |
| Overall denial rate | 18.3% | 6.8% |
| Days in AR | 58 days | 37 days |
| Imaging guidance capture rate | 45% | 96% |
| RFA first-pass auth approval | 33% | 83% |
| E/M distribution (% at 99214+) | 6% | 69% |
| Underpayment recoveries | $0 (none identified) | $31,200 |
Total revenue improvement year-over-year: $341,000
The improvement came from multiple sources simultaneously not a single dramatic fix, but a systematic correction of every gap that had been accumulating undetected under the previous billing operation.
What the Practice Said
At the one-year review, the practice manager summarized the experience this way:
“The audit was the thing that changed our thinking. We had convinced ourselves that if the billing was catastrophically broken, we’d know about it. What we didn’t understand is that billing can be quietly broken for years without anything obviously going wrong. Claims go out, money comes in, and you never see the gap between what you’re collecting and what you should be collecting.”
“The E/M number still gets me. We were documenting 99214-level visits and billing 99213 on nine out of ten of them. For years. That’s not a billing company problem that was just nobody ever looking.”
One of the physicians added:
“The RFA authorization improvement changed our scheduling workflow more than anything else. When 83% of your authorizations are approved on first submission instead of 33%, you’re not spending the first six weeks of every RFA cycle chasing documentation and waiting for peer-to-peer reviews. Patients get scheduled faster. The practice runs better. That part was unexpected I thought we were fixing a billing problem, and we also fixed a scheduling problem.”
Key Takeaways
This case study reflects a pattern we see consistently in pain management practices that come to us for a billing audit. The problems are rarely catastrophic. They’re quiet undercoding, documentation gaps, incomplete authorization packages, unreconciled payments each small enough to go unnoticed, all together large enough to represent hundreds of thousands of dollars in annual revenue that the practice earned and didn’t collect.
The specific issues that drove the most revenue recovery in this case:
E/M undercoding was the largest single gap – $90,720 per year from a coding habit that took one documentation conversation to fix. The clinical complexity was there. The documentation was there. The code level wasn’t reflecting either.
Imaging guidance was pure missed billing – not a coding error, not a denial, just a billable service that wasn’t being captured consistently. Once the pre-submission documentation verification was in place, the capture rate went from 45% to 97% and stayed there.
RFA authorization was a documentation process problem, not a clinical criteria problem. Every patient who got denied on first submission eventually got approved either on resubmission with documentation or through peer-to-peer. The delays and the five lost authorizations were entirely the result of incomplete authorization packages. The fix was procedural, not clinical.
Underpayment reconciliation recovered money that had been given away for years. Nobody at the practice knew the Cigna discrepancy existed. It wasn’t visible anywhere in the billing reports. It only showed up when someone compared ERA payments against the actual contract language.
Could Your Practice Have Similar Gaps?
Most pain management practices that haven’t had an independent billing audit in the past 12 months have at least some version of these issues. Not necessarily all of them, and not necessarily at the same dollar level but the pattern of quiet, compounding revenue loss from undercoding, incomplete authorization documentation, missed billing, and unreconciled payments is consistent across the practices we work with.
The only way to know for certain is to look.
Malakos Healthcare Solutions offers a free pain management billing audit – a review of your claims data, denial patterns, AR aging, coding distribution, payment reconciliation, and authorization history. Results are presented in specific dollar terms: what you’re currently leaving on the table, where it’s coming from, and what fixing it would recover.
No commitment. No obligation. Just a clear picture of where your practice’s revenue actually stands.
Schedule Your Free Pain Management Billing Audit
📞 +1 (307) 441-3431 ✉️ support@malakoshcs.com 📍 Cheyenne, Wyoming – Serving interventional pain practices across the United States
Malakos Healthcare Solutions | Pain Management Revenue Cycle Management | Serving interventional pain practices nationwide since 2022
