Four Pre-Denial Gaps Costing You Revenue

Hi and happy Tuesday,

Reviews across DSOs, specialty groups, and independent practices reveal four recurring pre-submission issues: missed benefit capture, early verification, missing or mismatched authorization proofs, and manual workflows that drain staff time.

Systematically resolving these gaps improves first-pass yield, raises collections, and frees staff for patient care.

1. Benefit capture misses

Teams assume standard benefits and skip plan-specific allowances (e.g., do not record full portal benefits, alternate benefits, or frequency resets).

Quick audit: 

• Audit the last 60 days of not covered determinations for perio and major services

• Re-verify in the portal and record alternate benefits, frequency limits, and reset dates in the chart

• Attach a portal screenshot to the encounter and select the paid code on the claim

Metric to own: Benefit capture before visit. Target above 95%.

2. Authorization and documentation gaps

Care is approved, but the proof is not attached, codes do not match the approval, or dates fall outside the window.

Checklist to standardize:

• Approval PDF attached to the chart

• Authorization number in claim notes

• Approved codes mirrored on the claim

• Dates inside the authorization window

The silent up-code opportunity:

Metric to own: Percent of high-value claims with proof attached. Target 100 percent.

3. Scheduling and verification timing

Verification is done early. The waiting period expires later. Treatment occurs before expiry. The claim is ineligible.

Operating rule

For major services, schedule at least seven days after the waiting period expiry. If earlier care is clinically necessary, collect payment in advance and queue the claim for the eligibility date.

Metric to own: Waiting-period scheduling compliance. Target 100%.

4. Labor inefficiency that suppresses throughput

Manual verification, benefit checks, and pre-auth tracking consume hours that could be used for billable care.

How to model it

• Measure minutes per verification by case type

• Convert time saved into additional cases per month using your average case value

• Track denial rate and days to submission before and after

Staff time recovery matrix:

Metrics to own: Average verification time under 15 minutes for complex cases. Days to submission under 45 days.

Exemplifying a successful case study

Key takeaway

Prevent losses before submission. Capture benefits at scheduling, attach proof on every high-value claim, enforce a seven-day eligibility buffer, and track four weekly metrics. Do these consistently and denial rates fall, collections rise, and staff time converts into billable care.

Next week, I will cover the 8 AI building blocks every practice needs to future-proof revenue.

See you next Tuesday,
Dino Gane-Palmer