How AMS uncovered years of recoverable revenue in a single review.
A persistent feeling that something was off
A solo optometrist in Arkansas had a nagging suspicion that something was wrong with her revenue cycle, but she couldn’t pinpoint it. Her in-house biller had received training, and the practice had even worked with an outside billing company in the past, yet collections felt persistently flat, and the AR balance kept climbing month after month.
The doctor reached out to AMS for a focused revenue cycle assessment, with a specific concern: she wanted to confirm that her coding and charge capture were accurate before assuming the problem lay elsewhere.
A targeted three-area assessment
AMS conducted a targeted assessment covering three areas:
- Charge capture and coding accuracy — reviewing clinical documentation to confirm providers were selecting appropriate codes and exam levels
- Clearinghouse rejection analysis — sampling TriZetto rejection queues from three claim batches (December 2025, January 2026, and February 2026)
- Payer remittance review — randomly sampling EOBs from January and February 2026 to verify payment outcomes and posting accuracy
A total of 31 claims were reviewed in detail: 17 drawn from the rejection queue, and 14 identified through random remit sampling.
The coding was accurate. The breakdown was administrative.
The good news came first: the providers were coding accurately. Exam levels were appropriate, procedures were correctly documented, and the clinical staff were selecting the right codes. The breakdown was happening entirely on the administrative side, between charge submission and payment collection.
Unworked Clearinghouse Rejections
17 claims from a single February batch had been sitting in the TriZetto rejection queue for over three weeks without correction. The root cause: a missing referring provider NPI in Box 17, required by most payers for diagnostic testing (OCT, photos, visual field). This issue was likely addressable with a single software configuration change in Eyefinity EPM, a one-time fix that would eliminate a recurring source of rejections.
What made the situation worse: some claims that slipped through the clearinghouse were still being denied at the payer level, and rather than being corrected and resubmitted as corrected claims (with the required resubmission code 7 in Box 22), they were either being written off or resubmitted as duplicates, neither of which results in payment.
Payer Denials Going Unanswered
10 additional denials were found through remit sampling, primarily from Aetna, UHC, and BCBS, citing inactive coverage or information requested. None had been worked. In several cases, partial payments had been posted, and remaining balances were simply adjusted off rather than corrected claims being filed, resulting in a direct write-off of legitimate revenue.
Additionally, the biller held an incorrect belief that diagnostic testing could not be billed on the same day as an office visit, a common misunderstanding that had been causing valid charges to be removed before submission.
EHR-to-EPM Data Integrity Issues
Multiple claims showed date-of-service mismatches between the EHR (clinical system) and EPM (billing system), as well as claims billed under the wrong rendering provider. These discrepancies were consistent with a software transfer issue rather than manual entry errors, but regardless of cause, they represent significant exposure if a payer were to conduct their own review.
Cataract Post-Op Claims Systematically Underbilled
Cataract post-operative encounters were being submitted without the required modifier 55, which signals to payers that the provider is managing post-op care. Without this modifier, payers deny the claim entirely. The fix requires: the 55 modifier, the cataract surgeon’s NPI in Box 17, the original surgery date in Box 14, and a notation in Box 19 documenting the assumed care period, all items that were consistently missing.
Refraction Revenue Being Left on the Table
In 12 of 31 reviewed encounters (39%), a refraction was performed but was never billed, either to insurance or to the patient. The practice had adopted a blanket policy of dropping the refraction charge because Medicare does not cover it. However, some commercial plans (specifically some Blue Cross and Humana plans) do cover refractions, and Medicare patients may be billed directly for a non-covered service.
Based on the sample alone, this represented approximately $600 in missed revenue. Annualized across the full patient volume, the cumulative loss is substantial.
Revenue impact and recommended actions
| Finding | Revenue Impact | Recommended Action |
|---|---|---|
| Missing Box 17 (Referring NPI) | 17 claims stalled; never reached the payer | Hard-code in EPM; correct and resubmit all affected claims |
| Unworked payer denials | 10 denials with balances written off | File corrected claims with code 7 and original ICN; prioritize by timely filing deadline |
| Cataract post-op missing modifier 55 | All co-managed post-op encounters were denied | Review and refile with modifier 55, Box 14, Box 17, and Box 19 |
| Refraction charges not billed (92015) | ~39% of encounters; hundreds per month annualized | Bill eligible payers; collect from the patient as a non-covered service |
| EHR-to-EPM data mismatches | Exposure if the payer conducts their own review; incorrect provider on claims | Escalate to EPM support; reconcile before submitting |
| AR balance: $1.7M / 616 avg. days | 80% of the balance is 150+ days past due | Triage by timely filing window; write off uncollectible; pursue recoverable claims |
Confirming what the doctor already suspected
One of the most important moments in the assessment meeting was when the provider shared her own attempts to make sense of the data:
“I was seeing that, and I was like, okay, I can’t understand. Let’s let somebody else do this.”
Solo Optometrist, Arkansas
That instinct, recognizing the limits of what she could see from inside the practice, was exactly right. The AMS reviewer confirmed that what she had noticed was real, explained why it was happening, and provided her with a clear, prioritized path forward.
Rather than a long list of criticisms of the biller, the meeting identified a more nuanced picture: knowledge gaps, a difficult software system with known limitations, and a workflow breakdown that had compounded over time, particularly since the practice migrated to a cloud-based version of Eyefinity EPM. The assessment gave the doctor the information she needed to have a productive conversation with her billing staff without it becoming adversarial.
A clear path forward
Following the assessment, AMS developed a proposal for a targeted biller training engagement, including an on-site visit to work directly with the billing staff on:
AMS also connected the practice with AMS’s Revenue Cycle Strategist to evaluate whether a software transition would be advisable, given the ongoing EPM challenges, and to ensure any training investment would not be undermined by the underlying platform.
What this case illustrates
Accurate coding doesn’t guarantee payment.
Clinical accuracy is necessary but not sufficient. The revenue cycle includes submission, rejection management, denial response, and AR follow-up, all of which can break independently.
Experience and knowledge are not the same thing.
A biller can have years of experience and still have gaps in specific areas, like corrected claim protocols, modifier requirements, or testing billing rules. Targeted training closes those gaps.
Small, recurring issues compound over time.
A missing modifier on every cataract post-op claim, or a refraction that never gets billed, these feel minor in isolation. Multiplied across months and years of patient volume, they represent significant lost revenue.
A focused assessment protects you proactively.
Date-of-service mismatches and wrong rendering providers are red flags in a payer review. Identifying and correcting them proactively is far less disruptive than responding to a formal notice.
AMS offers targeted revenue cycle assessments for medical practices.
We’ll tell you what we find, honestly, and give you a prioritized path forward.