The Power of RCM in Today’s Healthcare Practices.
As the CEO & Founder of GoHealthcare Practice Solutions, LLC, I’ve seen firsthand how Revenue Cycle Management (RCM) can make or break a medical practice. In today’s complex, fast-paced healthcare landscape, mastering RCM is no longer optional, it’s essential. With shrinking margins, increasing regulations, and patient financial responsibility at an all-time high, healthcare providers must adopt robust systems that optimize both front-end and back-end revenue processes.

One of the most powerful tools we deploy for our clients is athenahealth RCM, particularly athenaOne billing. Over the last five years, our expert team has partnered with practices to leverage athenahealth’s capabilities, streamline their revenue operations, and deliver measurable improvements in cash flow, claim resolution, and denial rates.

In this article, I’ll walk you through the secrets behind top-performing medical practices using athenahealth and how GoHealthcare Practice Solutions helps them stay ahead.

The Challenges of Revenue Cycle Management in 2025
Today’s practices face a host of challenges:

• Evolving payer rules and fee schedules
• Complex pre-authorization processes
• High patient deductibles and co-insurance
• Delayed reimbursements from both payers and patients
• Workforce shortages and training gaps

RCM isn’t just about sending out claims, it’s about managing the entire financial journey, from scheduling and verification to payment posting and appeals. Poorly managed RCM can lead to increased days in A/R, ballooning denials, and ultimately, lost revenue.

Why Top Practices Choose athenahealth
athenahealth is a cloud-based powerhouse that offers integrated solutions across clinical, financial, and operational workflows. Practices choose athenaOne billing because of its:

• Seamless claim scrubbing and submission
• Built-in payer rule updates
• Real-time insurance eligibility verification
• Integrated denial tracking
• User-friendly dashboards for KPI monitoring

At GoHealthcare Practice Solutions, we specialize in navigating and optimizing these tools. Our team has over 8 years of deep, hands-on experience with athenahealth (now athenaOne) across multiple specialties and practice sizes.

Secrets of High-Performing Practices Using athenahealth
High-performing practices that use athenahealth have a few things in common:

1. They Don’t Just Implement—They Optimize
These practices don’t treat athenahealth as plug-and-play. They customize it to align with their workflows, configure rules for claim edits, and set up tracking mechanisms for key metrics.
2. They Audit Constantly
Ongoing audits of claims, payments, and rejections help prevent revenue leakage. Automation makes it easier, but human oversight ensures nothing slips through the cracks.
3. They Train Staff Thoroughly
Top-performing teams know how to use athenahealth effectively. From front-desk staff to billing teams, everyone is trained and accountable.
4. They Use Partner Expertise
Working with a partner like GoHealthcare gives practices access to an RCM extension of their team—experts who live and breathe athenaOne billing daily.

Automation & AI in RCM
Automation and AI are transforming RCM. Within athenahealth, we implement features such as:

• Automated eligibility checks
• Intelligent claim edits based on payer behavior
• Denial prediction models
• Chatbots for patient balance reminders

These capabilities free up staff to focus on patient care and complex revenue issues, driving efficiency and reducing errors.

Patient Responsibility Management
With high-deductible plans on the rise, patient payments now represent nearly 35% of practice revenue.
Our team uses athenahealth to:

• Verify patient eligibility in real-time
• Generate accurate estimates before the visit
• Offer payment plans within the portal
• Send automated reminders via email or text

We help practices build trust while collecting more upfront.

Front-end Accuracy & Pre-authorization Processes
Revenue success starts before the visit.

Our strategy includes:

• Insurance verification 48 hours prior to appointments
• Authorization tracking logs built in athenahealth
• Training front-desk staff to collect required documentation
• Scripted communication templates for pre-service collections

By ensuring accuracy up front, we significantly reduce denials and delays downstream.

Denial Management & Reduction Tactics
Denials are a top cause of revenue loss. With athenaOne, we:

• Set up custom denial categories for precise reporting
• Route rejections to designated billing teams in real-time
• Track top 5 denial reasons by payer
• Set 48-hour turnaround goals for appeal submissions

Our team reduces initial denial rates to below 5%, with resolution rates above 90%.

Dashboards, KPIs, and Benchmarking Success
athenahealth provides dashboards that help us monitor key performance indicators (KPIs) such as:

• Clean claim rate
• First-pass resolution rate (FPRR)
• Average days in A/R
• Net collection rate
• Patient collections rate

Using these tools, we benchmark performance monthly and hold teams accountable with data-driven goals.

Our Expert Billing and Coding Strategies at GoHealthcare Practice Solutions
GoHealthcare Practice Solutions isn’t just another practice management company. Our process includes:

• Full athenaOne optimization audits
• A/R takeovers for aging claims
• Denial trends analytics with root cause corrections
• Weekly performance reviews
• Custom SOPs tailored to each client’s workflow

We act as an extension of your team, dedicated to improving collections, reducing denials, and driving operational efficiency.

Real Client Results:
Here are some recent results from our clients using athenahealth:

• Orthopedic practice in NJ: Reduced A/R over 90 days from 32% to 12% within 6 months.
• Multi-specialty clinic in TX: Increased patient collections by 22% through portal-based payment reminders.
• Cardiology group in CA: Achieved 98% FPRR by optimizing front-end claim edits.

These outcomes are achieved through consistent collaboration, system optimization, and expert oversight.

How We Reduce Denials and Days in A/R
Our formula:

• Root cause analysis of top denial reasons
• Daily rejection reviews in athenaOne
• Weekly appeal tracking meetings
• Real-time claim status updates
• Regular payer-specific training for staff

The result? Denials drop. A/R days shrink. Collections go up.

Staff Training and RCM Workflow Redesign
We believe people + process = performance. That’s why we:

• Train front-desk, billers, and coders on athena workflows
• Re-map processes to reduce manual entry
• Standardize documentation to minimize claim errors
• Align team KPIs with financial goals

When every stakeholder is aligned, the system performs better.

Top 10 RCM KPIs with Target Benchmarks

1. KPI Target Benchmark
2. Clean Claim Rate≥95%
3. First Pass Resolution Rate (FPRR)≥90%
4. Average Days in A/R< 35 days
5. Denial Rate< 5%
6. Net Collection Rate≥95%
7. Patient Collection Rate≥80%
8. No Response Rate< 10%
9. Days to Pay< 21 days
10. % of A/R > 90 Days< 10%

Authorization Compliance Rate100%
We help practices track and hit these benchmarks using athenahealth’s built-in tools.
athenaOne Optimization Tips from RCM Experts.

Here are some insider tips from our experts:

1. Use custom rules for charge edits to match payer nuances.
2. Automate recurring charges for predictable services.
3. Enable real-time eligibility alerts in scheduler view.
4. Use the task bucket system to streamline denial workflows.
5. Tag charges with custom attributes for performance tracking.
6. Review clearinghouse rejections daily and adjust scrubbing rules accordingly.
7. Optimize patient statements for clarity and response rates

With the right setup, athenaOne becomes your most powerful financial tool.
Achieving Financial Health in Medical Practices

RCM mastery isn’t a dream, it’s a decision.
At GoHealthcare Practice Solutions, we empower practices to unlock the full potential of athenahealth RCM through expert guidance, customized strategies, and relentless execution. We’ve helped clients across the country turn financial chaos into clarity.

If your practice is ready to elevate performance, reduce denials, and get paid faster, let’s talk.
Schedule a free consultation or revenue cycle audit today.

Let our team of athenaOne billing experts show you what’s possible.

Disclaimer: We are not contracted by, affiliated with, or endorsed by AthenaHealth in any capacity. We do not receive compensation, sponsorship, or any form of payment from AthenaHealth. All references to AthenaHealth are made for informational purposes only and do not imply any official connection.

How can I ensure my practice’s coding is accurate and compliant with Medicare and commercial payers?

Answer:
To maintain compliance and accuracy:

• Stay updated on Medicare Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).
• Use ICD-10 diagnosis codes that support medical necessity based on payer policies.
• Apply correct CPT codes with appropriate modifiers.
• Train staff regularly on payer policy updates and coding guidelines.
• Conduct internal audits to identify coding errors before claim submission.
• Ensure detailed and complete provider documentation supports billed procedures.

Working with experienced medical billers and coders can help prevent errors and compliance risks.

Claim denials are one of the most frustrating and costly obstacles in the revenue cycle of any healthcare practice. Whether you're managing a small medical office or overseeing billing operations for a large group practice, denied claims can lead to cash flow delays, staff burnout, and lost revenue. In 2025, as payers tighten policy enforcement and increase use of automated claim reviews, it’s more important than ever to adopt a disciplined, strategic, and proactive approach to denial resolution. This article walks you through a practical, step-by-step framework to understand, respond to, and reduce claim denials effectively.

Step 1: Understand the Types of Claim Denials
There are two primary types of claim denials:
1. Hard Denials: Permanent rejections that cannot be resubmitted. Examples include billing for non-covered services or missing filing deadlines.
2. Soft Denials: Temporary denials that can be corrected and resubmitted. These often involve coding errors, missing documentation, or lack of prior authorization.

Step 2: Identify the Root Cause
Before you take action, you must know why the claim was denied. Denial reason codes (CARC and RARC codes) explain the payer’s rationale. Common causes include:
- Incorrect patient demographics
- Invalid or missing modifiers
- CPT/ICD-10 mismatch
- Lack of medical necessity
- Missing prior authorization
- Non-covered services per policy

Step 3: Gather Your Documentation
To overturn a denial, your appeal must include:
- A clear explanation letter (appeal letter)
- A copy of the original claim
- Clinical documentation supporting medical necessity
- Authorization reference numbers if applicable
- Relevant medical policy or payer coverage criteria

Step 4: Write a Compelling Appeal
Your appeal letter should include the following:
• Patient name, DOB, date of service, and claim number
• Summary of the denial reason
• Clinical explanation of why the service was necessary
• Documentation highlights
• A clear request for reconsideration based on payer policy

Use clear and professional language. If possible, quote from the payer's own policy to strengthen your case.

Step 5: Track and Follow Up
Each payer has a different appeals window — some allow 30 days, others 90. Submit the appeal within the timeframe and track the status every week. Use a denial tracker to log:
- Date of denial
- Date appeal submitted
- Documents sent
- Contact names
- Outcome

Step 6: Implement Preventive Measures
Once you’ve addressed a denial, prevent it from recurring. Root cause analysis helps improve:
- Provider documentation training
- Coding and modifier use
- Pre-authorization workflows
- Eligibility verification and intake accuracy
- Payer-specific claim rules in your practice management system

Real-Life Case Example
A pain management practice submitted a claim for a lumbar RFA (CPT 64635). It was denied due to 'lack of medical necessity.' The denial team reviewed the documentation and found that the provider failed to list the prior diagnostic medial branch block results in the procedure note. They gathered the block results from a previous encounter, wrote an appeal citing the Medicare LCD policy that requires ≥50% relief after two blocks, and resubmitted the claim. The payer reversed the denial and paid the full amount.

Industry Denial Statistics in 2025:
Average denial rate for physician practices: 10–15%
- Top denial reasons: Prior authorization, coding errors, eligibility, non-covered services
- 80% of denied claims are recoverable — if appealed timely and accurately
- Practices lose 3–5% of total revenue annually due to preventable denials

References and Additional Reading:
Centers for Medicare & Medicaid Services (CMS) – Medicare Claims Processing Manual
• American Medical Association – CPT® 2025 Professional Edition
• Medical Group Management Association (MGMA) – Benchmarking Reports
• Healthcare Financial Management Association (HFMA) – Revenue Cycle Best Practices
• AAPC Knowledge Center – Appeals and Denials Management

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Why do insurance companies frequently deny pain management and orthopedic claims?

Answer:
Common reasons for denials include:

• Lack of medical necessity: Payers require thorough documentation proving the necessity of procedures.
• Incorrect or missing modifiers: Some orthopedic and pain management procedures require modifiers like 50, 59, or X-series modifiers for correct billing.
• Failure to obtain prior authorization: Many interventional procedures (e.g., spinal cord stimulators, radiofrequency ablation) require prior approval.
• Global period issues: If a procedure is performed within the global period of another surgery, it may be denied unless correctly coded.
• Bundling and NCCI edits: Certain procedures are considered inclusive of others and cannot be separately reimbursed unless exceptions apply.

Avoiding denials requires understanding payer policies, coding correctly, and submitting complete documentation.

🔍 What Is Pain Management Billing and Coding?
Pain management involves diagnosing and treating chronic pain using interventional procedures like injections, ablations, and implants.
✔️ Your job as a biller or coder:

• Translate what the provider did into CPT codes
• Match that service with the correct diagnosis (ICD-10)
• Add modifiers and place of service codes
• Ensure documentation supports medical necessity
• Submit claims to insurance (correctly) the first time

✍️ Understanding CPT Codes in Pain Management
Let’s break down real CPT codes line-by-line. These are not just numbers — they are full sentences describing what was done.

📌 A. Facet Joint Injections (Cervical, Thoracic, Lumbar)
CPT 64490
Injection, paravertebral facet joint (cervical/thoracic), single level, with image guidance
➤ Use for the first level treated in the neck or upper back
➤ Add 64491 for the second level
➤ Add 64492 for the third level (only bill once per session)
What to document:

• Level injected (e.g., C4-C5)
• Side treated (right/left/bilateral)
• Type of medication injected
• Image guidance used (fluoro or CT)
• Diagnosis (e.g., M54.2 — cervicalgia or M54.12 — cervical radiculopathy)

📌 B. Radiofrequency Ablation (RFA)
CPT 64635
Destruction by neurolytic agent, lumbar/sacral facet joint nerve(s), with image guidance; single level
➤ Add 64636 for the second and third levels
Key points:

• Always document the result of prior diagnostic medial branch blocks
• Use radiculopathy diagnosis codes, not just “back pain”
• Include pain relief % (typically ≥ 50% for approval)

📌 C. Epidural Steroid Injections (ESIs)
CPT 64483
Injection, anesthetic/steroid, epidural space, lumbar, transforaminal, single level
CPT 62323
Injection(s), interlaminar epidural (lumbar/sacral) with imaging
What to link with it:

• Diagnosis like M54.16 (lumbar radiculopathy)
• Prior failed treatment (NSAIDs, PT)
• MRI report showing nerve compression
• Pain score and duration (e.g., 6/10 pain for 6 months)

📌 D. Trigger Point Injections
CPT 20552
Injection(s), 1–2 muscles
CPT 20553
Injection(s), 3 or more muscles
Common documentation issues:

• No muscle names listed
• No exam finding (taut band, spasm)
• Diagnosis mismatch (use M79.1 — myalgia)

📌 E. Spinal Cord Stimulator (SCS)
CPT 63650
Percutaneous implantation of epidural neurostimulator trial lead
CPT 63685
Insertion of spinal neurostimulator pulse generator (permanent)
Billing tips:

• Always obtain pre-auth for both trial and implant
• Document psych clearance, successful trial result, and failed conservative care
• Use diagnosis like G89.29 (chronic pain) + radiculopathy

📌 F. Peripheral Nerve Stimulator (PNS)
CPT 64555
Lead placement on peripheral nerve
CPT 64590
Insertion of generator
Make sure:

• Nerve is named in the procedure note (e.g., occipital, femoral)
• Trial result is clearly documented
• Prior treatment attempts are noted

📌 G. Kyphoplasty
CPT 22513
Percutaneous vertebral augmentation (e.g., balloon kyphoplasty), thoracic
What payers want to see:

• Acute fracture diagnosis (e.g., S32.010A)
• MRI/X-ray report
• Failed back bracing and conservative care
• Pain limiting function

📌 H. SI Joint Fusion
CPT 27279
Minimally invasive SI joint fusion (iFuse, Rialto)
Payers require documentation of:

• 6 months of SI joint pain
• 2+ positive diagnostic SI joint injections
• Imaging (X-ray, CT, MRI)
• Functional loss documentation (e.g., difficulty sitting/walking)

🧾 Real-Life Billing Workflow for a Pain Management Practice
Let me walk you through the step-by-step process of billing a real RFA case:

1. Provider performs medial branch block (MBB) → CPT 64493
2. Patient reports 80% relief for 6 hours → ✅
3. Provider schedules RFA
4. Pre-authorization is submitted
5. Claim is submitted with:
   • CPT 64635
   • ICD-10 M54.16
   • POS 11 (office) or POS 24 (ASC)
   • Provider NPI and signature
6. Insurance responds with payment or denial
7. If denied, appeal with documentation including block result, imaging, and provider narrative

🧠 Modifiers and Denial Prevention
Here are common modifier tips:

• -RT / -LT = Right or left side
• -50 = Bilateral (don’t use with -RT or -LT on same line)
• -59 = Distinct procedural service (use with care!)
• -25 = E/M service on same day as a procedure (must be separate and documented)

📚 Documentation = Payment
No matter how clean your codes are, you won’t get paid without supporting documentation.
You must include:

• Procedure notes
• Pain scores
• Imaging results
• Failed treatments
• Specific diagnoses
• Patient function impact (can’t sit, walk, sleep, work)

🏁 Final Tips
Treat every CPT code like a sentence. Ask yourself:

• What was done?
• Why was it medically necessary?
• What does the documentation say?

If you can’t answer all three, the claim is at risk of denial.

📚 References & Additional Reading

• AMA CPT® 2025 Professional Edition
• CMS LCD Policies: Noridian, Novitas, Palmetto (Pain Management)
• AAPC Pain Management Coding Guidelines
• Medicare Claims Processing Manual, Chapter 12
• Commercial Payer Medical Policy Portals (Aetna, Cigna, UHC, BCBS)