The billing health check:

Pull up your billing reports and you’ll usually find something worth worrying about. What you won’t always find is what’s causing it.

In TheraNest webinar Q&As, this comes up frequently. Therapists tell us they have a lot of data, but they lack the context needed to interpret it. A high 90-day A/R balance could trace back to your front desk intake process, your claim submissions, or a payer that’s slow on reimbursements, and each of those has a different fix. Same with denials: some are worth appealing, some point to a pattern you need to stop creating, and the number itself doesn’t sort them for you.

This post is a triage guide. It won’t re-explain what A/R aging is. It will help you figure out where your revenue leak is actually coming from and what to address first.

Start with your A/R aging report: it’s your baseline

A/R aging is the right first stop because it tells you whether money is moving through your practice at a healthy pace or stalling somewhere in the pipeline. 

Most EHRs offer billing reports that divide outstanding balances into buckets by age:  

• 0-30 days 

• 31-60 

• 61-90 

• 90+ 

A well-functioning practice collects the majority of what it’s owed well before claims reach the 90-day mark. For Medicare, federal regulation requires clean claims to be paid within 30 days of receipt. Commercial payer timelines vary by state, prompt payment law, and contract terms, but most payer agreements set similar expectations around the 30-45 day range. 

The number to watch is your 90+ day bucket. If more than 15-20% of your total A/R sits there, that’s a signal worth investigating, though the right benchmark varies by payer mix and practice type, so treat any threshold as a starting point rather than a hard rule. What you’re looking for is trend, not a single snapshot: is that bucket growing month over month, or holding steady? 

One less obvious warning sign: an inflated 0-30 day bucket. If a large share of your A/R is always “new,” it can mask a chronic submission problem where claims are regularly re-entering the pipeline after rejection rather than moving forward.

Denial patterns are the diagnosis, not just the symptom

A single denied claim is a claim problem. A cluster of denied claims from the same payer, for the same service code, over the same 60-day window is a process problem, and it has a different fix. 

The distinction matters because most billing platforms and clearinghouses surface denials as individual events. It takes a deliberate step back to look at them as a pattern. Pull your denial report and sort it two ways: by payer, and by denial reason code. You’re looking for any combination that repeats. 

CMS publishes guidance on common claim adjustment reason codes (CARCs), which are the standardized codes payers use to explain denials. Codes related to authorization and modifier issues – such as CO-4 (modifier inconsistency) and CO-15 (missing or invalid authorization number) – tend to indicate front-end workflow gaps: eligibility wasn’t verified, authorization wasn’t obtained, or the service wasn’t covered under the submitted modifier. These are fixable upstream.  

Codes indicating untimely filing require a different response: reviewing whether your submission workflows have a timing gap, and whether any claims can still be appealed within the payer’s window. 

The prioritization rule: sort your denial categories by volume multiplied by average dollar value, not by denial type alone. A high-volume, low-dollar denial category often costs more to chase than it recovers (the average cost of reworking a denied claim is around $43.84 per claim, though that number can climb to over $100). A low-volume, high-dollar category from a major payer is almost always worth addressing immediately. 

Explore claim denial management strategies for building standardized workflows that help resolve denials faster and more efficiently.

Payment leaks are harder to see

Unlike denials, payment leaks don’t announce themselves. They show up — if at all — as small discrepancies that are easy to rationalize away. 

The most common sources are underpayments, unbilled charges, and uncollected client balances. 

Underpayments happen when a payer reimburses less than your contracted rate. The only way to catch them is to cross-reference the payment amount on each Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) against your fee schedule for that payer. CMS provides guidance on reading and reconciling ERAs, and the same reconciliation principle applies to commercial payers. This step gets skipped most often in busy practices, and that’s exactly when underpayments accumulate quietly over months. 

Unbilled charges are revenue that never enters your A/R system at all. A session that gets documented but not charged, a missed add-on code, a telehealth modifier that wasn’t applied: these produce a gap between what you delivered and what you ever asked to be paid. Reconciling your appointment records against your charge entries at least monthly is the simplest way to catch this. 

Uncollected client balances — copays and deductibles not collected at the time of service — are a front-end problem that becomes an accounts receivable problem. The American Medical Association notes that point-of-service collection reduces accounts receivable, lowers back-end collection costs, and decreases the administrative burden of tracking unpaid balances. Collecting at the point of service isn’t just a convenience; it’s a recovery rate issue.

How to triage: Which problem to fix first 

If you’re looking at all three problem areas and don’t know where to start, use this sequence: 

1. Run your denial report first. Denials are time-sensitive. Under federal rules governing most health plans, you typically have up to 180 days from denial to file an internal appeal – though windows vary significantly by payer. (UnitedHealthcare’s commercial deadline, for example, is 65 days.) Missing that window means the revenue is gone regardless of whether the denial was legitimate. Find your highest-dollar recurring denial category and work that one before anything else. 
2. Then look at your 90+ day A/R bucket. Identify the top three payers by dollar amount in that bucket and check the status of those claims. If they’ve been submitted and not responded to, that’s a follow-up task. If they were denied and not appealed, that’s a recovery opportunity if you’re still within the appeal window.. 
3. Payment leaks, particularly underpayments, are lower urgency but worth building into a monthly reconciliation habit rather than a one-time audit. 

A billing problem you can name is a billing problem you can fix. The goal of this kind of review isn’t to find everything at once, it’s to find the highest-impact issue in your specific practice, address it, and build the habit of looking again next month. 

If you’re finding patterns that feel bigger than a one-person fix, Ensora Health’s revenue cycle management services are built to help practices like yours get – and stay – ahead of them.