You cannot collect money for a visit you never billed. That sounds obvious, but it happens more than most owners would guess. The patient came in. The doctor did the work. Everyone went home. Somewhere between the exam room and the billing system, the charge disappeared, and nobody noticed.
A dermatologist in Savannah once told me, “We’re booked six weeks out and I’m looking at empty chairs. It makes no sense.” Her office manager, Felicia, ran twelve months of scheduling data, and we went through it together on a speakerphone. About 22 percent of medical dermatology appointments were no shows. At roughly 180 visits a day and $115 a visit, that came to about $4,600 a day, more than $1.1 million a year, in visits that never turned into a charge. Nobody in the office had compared the schedule to what happened, because every morning the schedule looked full. Once they added automated reminders and backfilled cancellations from the wait list, no shows fell to 7 percent and the practice got back roughly $780,000 a year. Since then, the schedule sitting next to the billed charges is the first report I ask any practice for.
What still surprises me is how lopsided the attention is. Practices will spend hours working denial reports and rarely look for the charges that never made it into the system. A denial at least gives your team something to work. A missing charge gives you nothing. No warning, no report, and no money.
Why missing charges are invisible
Pull your monthly billing reports and everything may look fine. Your denial rate is reasonable. Claims are getting paid. But those reports cannot tell you about the office visit that never got billed or the injection nobody entered. As far as your billing reports are concerned, those services never happened.
That is why a practice has to go looking for missed charges on purpose. They will never show up in a work queue on their own.
Where charges go missing
Most missing charges do not come from a complicated billing failure. They come from ordinary things that happen in a busy medical office.
Unsigned notes. In my experience, they are one of the most frequent culprits. When the provider has not signed the note, the charge sits in a pending state, and if nobody follows up, it sits there indefinitely.
Procedures that never make it onto the claim. A patient comes in for an office visit and ends up needing an EKG or an injection. The provider documents the visit, the office visit gets billed, and everyone moves on. Three weeks later, somebody realizes the procedure was never charged. That is assuming somebody notices at all.
Drugs and supplies. Vaccines, injectables, splints, and wound care supplies carry their own codes, and they get skipped when the person entering charges is working from the visit summary rather than the full note.
The 4:45 add on. A patient squeezed in at the end of the day falls outside the normal check in and check out flow. The front desk is closing the drawer, the encounter never gets closed out, and the charge goes nowhere.
Telehealth visits. When telehealth runs through a separate platform, those encounters frequently miss the step that creates the charge.
The 10 minute routine
This does not require a committee, another software subscription, or a complicated new workflow. Somebody needs to spend a few minutes before closing comparing three things: who came in, what got documented, and what made it into billing.
I would start with four simple checks.
Step 1: Look at today’s schedule. Every patient should show either a completed visit or a no show or cancellation marked. Anybody in between needs an answer before you leave.
Step 2: Make sure every completed visit has a charge. If it does not, flag it.
Step 3: Make sure every charge turned into a claim. Look for anything stuck on hold.
Step 4: Write down what you found and who is fixing it. Patient, provider, what is missing, and who owns it by when.
The first few times can take 20 minutes, and longer if your workflow is messy. That is fine. The goal is to build the habit. Ten minutes is a reasonable target for a small office once the routine settles in. A larger practice or one with a lot of providers will take longer, and that is fine too.
And put one person in charge. Not the billing department. Not the front office team. One person whose responsibility is to make sure it gets done. Give that person a backup for vacations and sick days.
Handling unsigned notes
One unsigned note is easy to fix. Twenty unsigned notes from three different providers are another matter. By then, people are trying to remember details from visits that happened two weeks ago, and the billing team is chasing doctors who moved on to the next hundred patients. That is a miserable way to run a revenue cycle.
Set a target for how quickly notes get signed and charges get entered. Same day or next day is a common standard for office visits. Pick a target your providers can meet, then hold to it. Each morning, send each provider a short list: patient name, date of service, and the note waiting for a signature. Keep it short so it gets read.
Tracking charge lag as a KPI
Charge lag is the number of days between the date of service and the date the charge is entered. Track it, and break it out by provider.
If one physician is getting charges entered the same day and another sits five or six days behind, I would want to know why. The second physician may be buried in documentation. The templates may be clumsy. It may be that nobody ever showed them how much the delay affects cash flow. Whatever the reason, you found something you can fix.
Charge lag also shows up in your cash flow. Cut charge lag from five days to one and you take four days out of the process before the claim can even get moving. That does not guarantee the payer will pay any faster, but it removes four days of waiting that sat fully within the practice’s control.
How HARRIS CareTracker helps
This is one of those areas where the software you use makes a difference. When your scheduling system, EHR, and billing software do not talk to each other, finding missing charges turns into a daily exercise in exporting reports and comparing spreadsheets. Nobody wants to do that at 5:00 on a Friday.
HARRIS CareTracker brings scheduling, clinical documentation, and billing together. Rather than piecing information together from separate systems, your billing team can find encounters that never got billed and deal with them before they become another forgotten item on somebody’s list. Claims built from those charges also run through automated claim scrubbing before submission, which protects your clean claim rate and keeps days in A/R from creeping up.
Here is what I would do tomorrow morning. Pull yesterday’s appointment schedule. Compare it to the charges entered. Count the patients who came in but never made it into billing.
The answer may be zero. I hope it is.
If it is not, you found money your practice earned and was on track to never collect. Ten minutes is a small price to find out.
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About the Author
Thomas Koehl is a 30 year health technology veteran and currently Director of Marketing at Harris CareTracker. Prior leadership roles at QRS Healthcare Solutions focused on supporting revenue cycle management partners. Following Hurricane Katrina, he served as Director of a large New Orleans medical clinic that delivered care to over 32,000 patients. Koehl has testified before the U.S. House Committee on Energy and Commerce as an expert witness on disaster healthcare delivery. He also volunteers as COO of International Medical Alliance, a nonprofit providing free medical care to impoverished communities in developing countries. He writes about the business, strategy, and human side of health technology for the practitioners and leaders living it day to day.
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