Case Study: Recovering a $28,700 NICU Claim in Neonatal Billing Operations
How a Texas-based NICU group turned a denied claim into recovered revenue—and fixed recurring billing gaps in under 60 days.
Introduction
A well-regarded neonatal group in Texas lost $28,700 on a denied NICU claim. The denial was issued by a commercial payer citing “duplicate billing” and “non-covered level-of-care documentation.” Despite the critical nature of the services, the claim was flagged due to inconsistent coding and missing care-level justification.
In March 2025, Medical Billing Wholesalers was brought in. Within 55 days, our Neonatal Denial Management Team recovered the full amount and implemented billing improvements that reduced future claim risks significantly.
Client Overview
The case involved a multi-provider group offering 24/7 neonatal care, including NICU coverage and complex newborn procedures.
Specialty: Neonatal Billing & Coding Services
Location: Texas, US
Average Case Value: $20,000–$35,000
Our Service: Denial Management Services
Challenges
The neonatal group experienced recurring claim rejections due to operational and coding limitations:
Incorrect Level-of-Care Codes
The claim lacked appropriate modifier use and CPT/HCPCS alignment with NICU levels.Duplicate Billing Conflicts
Multiple providers billed overlapping time blocks without supporting team-based care documentation.Missing Justification for Prolonged Care
The clinical notes didn’t reflect the severity and duration of newborn conditions.Delayed Appeals Tracking
Internal teams often missed deadlines due to lack of denial categorization workflows.
Many neonatal practices face similar revenue setbacks. Learn how outsourcing neonatal billing can reduce rejections and speed up payments.
Our Approach
To address the root causes of denial, we launched a targeted intervention involving cross-functional teams from coding, clinical documentation, and denial management.
A structured recovery strategy was developed, combining neonatal coding audits, clinical coordination, and payer-aligned appeals planning.
Analysis
| Challenge | Solution Implemented |
|---|---|
| Incomplete level-of-care coding | Neonatal-specific code sets and modifiers were reviewed and corrected by certified coders. |
| Duplicate billing detected | Time logs and co-management notes were compiled to justify shared provider billing. |
| No severity justification | NICU progress reports and neonatal resuscitation details were attached to appeals. |
| Appeals delays due to tracking | A centralized denial categorization system was created with payer-specific alerts. |
Results
$28,700 was successfully recovered through a clean and documented appeal.
Denials related to level-of-care were reduced by 53% in 60 days.
Appeals filing accuracy improved by 70% with template-based submissions.
Approval rate for NICU procedures rose to 94%, up from 66%.
Claim-to-payment cycle time was shortened by 43% using a centralized denial dashboard.
Conclusion
With Medical Billing Wholesalers’ Neonatal Billing & Denial Management Services, this neonatal group recovered major lost revenue and improved accuracy across coding, documentation, and appeal workflows—laying a strong foundation for sustainable revenue growth.
🗣️ “We weren’t just losing money—we were losing time explaining claims that should have been approved on day one.” – Practice Manager, Neonatal Group
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