Build It Right, Then Make Sure It's Working
Part Two: How Operational Consulting Can Help Private Practices Prevent and Manage Denials
In Part One of this series, we looked at a critical reality facing private medical practices:
Many claim denials begin long before the claim reaches the billing department.
Registration, eligibility verification, prior authorization, credentialing, documentation, EHR configuration, and staff workflows can all influence whether a claim gets paid correctly the first time.
That raises the natural next question:
What can a practice do about it?
The answer starts before the doors open—and continues long after.
Build Before You Have to Repair
For a new private practice, there is an important window before opening when operational infrastructure can be intentionally designed.
An experienced healthcare operations consultant can help establish that infrastructure across several critical areas.
Credentialing and Payer Readiness
Providers should know which payer enrollments are complete, effective dates, participation status, CAQH status, payer-specific requirements, payer portals, and related enrollment requirements before claims begin flowing.
Credentialing problems can themselves create significant financial disruption.
In an MGMA poll, 54% of medical practices reported that credentialing-related denials had increased, with practice leaders citing payer processing delays, communication problems, and changing requirements.¹
Patient Registration and Eligibility
Staff should know exactly which demographic and insurance information must be collected, how it should be entered, when eligibility should be verified, who performs the verification, and what happens when coverage cannot be confirmed.
Prior Authorization
The practice should establish which services commonly require authorization, who is responsible for obtaining it, where authorization information is documented, how expiration dates are monitored, and what happens when authorization cannot be obtained.
EHR and Practice-Management Configuration
Technology should support the workflow—not dictate it.
Registration fields, insurance information, provider data, scheduling workflows, documentation templates, claim edits, and work queues should be configured around clearly defined processes.
Revenue-Cycle Handoffs
Who owns what?
Responsibilities among scheduling staff, front-office employees, clinical personnel, providers, coders, practice management, and the billing company should be clearly defined.
Without that clarity, tasks can fall between departments—and claims can fall with them.
Consider Two New Practices
Imagine two private practices with similar providers, payer mixes, patient volumes, and $1 million in annual gross charges.
Practice A opens with limited operational infrastructure and develops processes as problems occur.
Suppose it ultimately experiences a 12% initial denial rate.
That's $120,000 in charges entering the initial denial workflow.
Practice B establishes its workflows before opening—credentialing oversight, eligibility verification, authorization processes, staff training, EHR workflows, billing handoffs, and performance monitoring.
Suppose it maintains a 5% initial denial rate.
That's $50,000 in charges entering the initial denial workflow.
The difference is $70,000 in charges per $1 million billed that do not initially enter the denial process.
This is an illustrative model—not a guarantee that hiring an operations consultant will produce a 5% denial rate or $70,000 in additional revenue.
The potential financial benefit comes from something broader:
faster cash flow, less rework, fewer appeals, reduced risk of write-offs, greater staff productivity, and improved revenue predictability.
But there is an important catch.
Opening the Practice Isn't the Finish Line
A consultant can help design excellent workflows before launch.
But no one truly knows how those workflows will perform until real patients begin moving through the practice and real claims begin reaching payers.
Launch provides something planning cannot:
real data.
That's why operational involvement shouldn't necessarily end when the doors open.
The first months provide an opportunity to compare what was designed against what is actually happening.
Are staff following the eligibility workflow?
Are authorizations being obtained?
Are providers completing documentation appropriately?
Are claims being submitted cleanly?
Which payers are denying claims?
Why?
Are the same denial reasons appearing repeatedly?
And most importantly:
Is someone responsible for doing something about what the data is telling the practice?
Create the Feedback Loop
A healthy revenue cycle should create a continuous connection between billing information and practice operations:
Measure → Identify → Analyze → Correct → Educate → Measure Again
MGMA recommends regular review of denial reports, categorization of denials, and root-cause analysis rather than simply correcting individual claims.
More recent MGMA guidance has reinforced the value of a standing denial-management cadence, including reviewing denial reports at least monthly and examining recurring patterns collectively.²
The principle is straightforward:
Denial prevention needs ownership.
If a billing company corrects the claim but nobody fixes the workflow that created the denial, the practice remains vulnerable to generating the same problem repeatedly.
What Should Someone Be Watching?
Once claims begin flowing, practice leadership should routinely evaluate indicators such as:
- Initial denial rate
- Top denial reasons
- Clean-claim or first-pass acceptance rate
- Days in accounts receivable
- A/R greater than 90 days
- Eligibility-related denials
- Authorization-related denials
- Documentation-related denials
- Credentialing-related denials
- Payer-specific denial patterns
- Appeal success rates
- Payer underpayments
- Net collection rate
The objective isn't simply to produce another dashboard.
The numbers should trigger action.
If authorization denials increase, determine why.
If one payer's denials spike, investigate.
If A/R over 90 days begins growing, find the bottleneck.
If registration errors repeatedly generate denials, correct the workflow and retrain staff.
That's operational management—not merely reporting.
The First 90 Days Matter
For a newly opened practice, a structured stabilization period can be especially valuable.
First 30 Days — Validate
Determine whether the workflows established before opening are actually being followed. Monitor registration, eligibility, authorizations, scheduling, documentation, collections, and billing handoffs.
Days 31–60 — Identify
As claim volume develops, begin identifying patterns. Which payers are denying claims? Why? Are problems isolated or recurring? Are denied claims being worked promptly?
Days 61–90 — Correct and Stabilize
Perform root-cause analysis. Modify workflows. Retrain staff. Adjust SOPs. Address technology issues. Clarify responsibilities and establish baseline KPIs.
After stabilization, the cadence can evolve into monthly or quarterly operational and RCM oversight.
MGMA has reported that among surveyed medical group leaders conducting payer-payment audits, 30% reported auditing monthly and another 18% quarterly, demonstrating the role recurring oversight can play in revenue-cycle management.³
From Builder to Monitor to Advisor
This is where an operations consultant's role can evolve naturally.
Before opening: Builder
Design the operational infrastructure.
After launch: Monitor
Compare real-world performance against the systems that were designed.
During stabilization: Problem Solver
Identify root causes and correct workflows before bad habits become embedded.
Long term: Advisor
Periodically review performance, identify emerging risks, maintain accountability, and help leadership optimize operations as the practice grows.
The objective isn't to make a practice permanently dependent on a consultant.
It is to help create an organization capable of recognizing problems, understanding their causes, and continuously improving.
Some practices will eventually have internal leadership capable of owning this completely.
Others may benefit from continued monthly or quarterly operational oversight.
Either way:
Someone needs to own it.
Build It. Measure It. Improve It.
No consultant, billing company, technology platform, or workflow can eliminate every denial.
Payer policies change.
Medical-necessity determinations occur.
Authorization requirements change.
Human errors happen.
The goal isn't zero denials.
The goal is to prevent the avoidable ones, identify recurring problems quickly, and ensure that yesterday's denial doesn't become tomorrow's standard operating procedure.
For physicians opening a private practice, perhaps the question shouldn't simply be:
"Who is going to handle my billing?"
Ask instead:
"Have I built a practice that gives my billing operation the best possible chance of getting me paid correctly the first time?"
Then, after opening:
"Who is making sure the system continues to work?"
Because a successful practice isn't simply one that opens correctly.
It's one that continues checking whether what was built is actually working.
References
1. Medical Group Management Association (MGMA). “More Than Half of Practices Report Credentialing-Related Denials on the Rise.” In an MGMA Stat poll, 54% of medical practices reported increased credentialing-related denials.
2. Medical Group Management Association (MGMA). “Your Best Biller Can't Fix Your Denial Rate Alone,” 2026. MGMA discusses standing denial-prevention cadence, regular denial-report review, root-cause analysis, and clear ownership of denial prevention.
3. Medical Group Management Association (MGMA). “Regular Auditing of Payer Payments Crucial to Ensure Accurate Reimbursement.” Among surveyed medical group leaders conducting payer-payment audits, 30% reported auditing monthly and 18% quarterly.