Introduction
This case study explores how Medical Billing Wholesalers, a trusted partner in ABA therapy billing services, collaborated with a Phoenix-based clinic to transform its billing performance. By implementing targeted strategies to fix coding inaccuracies, streamline authorizations, and expedite reimbursements, MBW significantly improved the clinic’s revenue cycle.
Client Overview
Location: Phoenix, Arizona, USA
Specialty: ABA Therapy for children with autism
Monthly Patient Volume: Approximately 300
Monthly Revenue Cycle Volume: $250,000
Average Monthly Collections: $150,000
The clinic struggled with persistent billing challenges including delayed reimbursements, high denial rates, and underpayment recovery gaps—common issues faced by ABA providers across the U.S.
Challenges
Through a comprehensive audit, MBW identified four key challenges that were directly impacting the clinic’s revenue:
Inaccurate Coding and Modifier Usage
Frequent errors in CPT/HCPCS codes and therapy-specific modifiers caused claim rejections and delays.Authorization and Eligibility Gaps
Outdated or missing prior authorizations and lack of real-time ABA eligibility verification led to denied claims and unpaid services.Delayed Reimbursements
Claims took an average of 60 to 90 days for resolution due to ineffective follow-up and escalation processes.Underpayment Recovery and Transparency
The clinic lacked a structured system to identify underpaid claims or track insurance payment variances accurately.
Our Approach
To address these challenges, MBW implemented a comprehensive, multi-layered strategy aimed at standardizing processes, automating workflows, and aligning with payer-specific requirements.
Analysis
By executing our strategy, we identified the root causes and delivered tailored solutions that drastically improved billing performance:
| Challenge | Solution Implemented |
|---|---|
| Inaccurate Coding and Modifier Usage | Our certified behavioral health coders conducted coding audits to align procedure codes (97151, 97153, 97155) with documentation. Modifier logic was automated based on payer guidelines and provider credentials, reducing errors tied to HO, HN, and U-series codes. |
| Authorization and Eligibility Gaps | We implemented a live authorization tracker and switched to real-time eligibility verification, preventing expired approvals and improving pre-visit coverage checks. |
| Delayed Reimbursements | Our team began claim follow-ups on day 21 and introduced structured A/R reviews with escalation workflows, cutting down resolution time drastically. |
| Underpayment Recovery and Transparency | We rolled out an automated payment posting and tracking system and provided actionable reports to flag and recover insurer underpayments. |
Results
Within just 90 days, the clinic saw measurable and industry-aligned improvements:
Claim Denial Rate: Reduced from 27% to 6%
Average Days in A/R: Reduced from 78 days to 32 days
First-Pass Clean Claim Rate: Increased from 61% to 94%
Authorization-Related Denials: Dropped from 18% to 3%
Coding and Modifier Errors: Reduced from 23% to 4%
Underpayment Recovery Rate: Increased significantly
Reconciliation Time: Improved by over 40%
These improvements stabilized cash flow, reduced administrative burden, and allowed providers to focus on patient outcomes rather than insurance paperwork.
Conclusion
By partnering with ABA billing experts, this Phoenix-based ABA clinic not only reversed its billing setbacks but also created a strong foundation for sustainable revenue growth. Our tailored interventions helped reduce denials, improve accuracy, and recover missed revenue.
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