GoHealthcare Practice Solutions Case Study
How GoHealthcare Practice Solutions connected professional and facility billing, strengthened charge capture, reduced preventable denials, and improved reimbursement visibility.
Engagement Overview
A specialty surgical practice and its affiliated ambulatory surgery center were operating with disconnected professional and facility revenue cycle workflows.
The physician practice and ambulatory surgery center treated the same patients and supported the same procedures, but authorization, coding, charge capture, claim submission, denial management, and payment reconciliation were handled through separate processes.
GoHealthcare Practice Solutions was engaged to connect the professional and ambulatory surgery center revenue cycle processes and establish stronger controls from scheduling through final payment.
The Client
The client was a specialty medical practice performing procedures in an affiliated ambulatory surgery center. The organization managed both professional services rendered by physicians and facility services delivered by the ambulatory surgery center.
Each entity had distinct billing systems, claim forms, fee schedules, payer contracts, coding requirements, reimbursement methodologies, and accounts receivable processes. Although the clinical care was connected, the revenue cycle operations were not.
Identifying information has been removed to protect client confidentiality.
The Challenge
Authorization details were not consistently shared between the physician practice and ambulatory surgery center, creating risk around approved procedure, provider, facility, site of service, effective dates, and payer limitations.
Procedure codes, diagnoses, laterality, anatomical levels, modifiers, units, implant information, provider data, and site-of-service details did not always flow consistently across teams.
Professional and facility charges were not always reconciled after each procedure, creating exposure to missed claims, missing implants, unbilled supplies, and delayed revenue.
Different claim-generation and submission timelines made it difficult to determine whether both entities had fully billed each completed procedure.
Professional and facility denials were worked independently, even when the same authorization, coding, or site-of-service issue affected both claims.
Leadership lacked a unified view showing whether both claims were submitted, accepted, paid, underpaid, denied, or still unresolved.
Operational and Financial Risk
Completed procedures could remain partially billed or unbilled.
Professional and facility services could proceed without fully aligned authorization details.
Differences between physician and facility claims could trigger payer review or claim disruption.
The same underlying issue could generate separate denials across both entities.
High-cost devices and supplies could be omitted, underreported, or reimbursed incorrectly.
Management could not easily determine whether the full financial lifecycle of each procedure had been resolved.
GoHealthcare’s Approach
GoHealthcare evaluated the full procedural workflow from patient scheduling through final professional and facility payment. The engagement connected the two revenue cycles while preserving the distinct billing and compliance requirements of each entity.
GoHealthcare mapped the complete workflow across patient access, authorization, operative documentation, coding, professional charge entry, facility charge entry, claim submission, denial management, payment posting, and final reconciliation.
A structured review confirmed the approved procedure, provider, facility, site of service, effective dates, units, network requirements, referral requirements, and payer-specific limitations for both entities.
Each completed procedure was reconciled to confirm that both professional and facility charges were entered and aligned with the operative documentation.
Exception-based controls were established to identify missing professional charges, missing facility charges, unbilled implants, supplies, medications, ancillary services, and charges held for documentation or coding review.
Professional and facility coding were reviewed as related but distinct functions. The process evaluated whether the claims accurately reflected the operative report, procedure, diagnosis support, laterality, levels, units, modifiers, device use, and site of service.
GoHealthcare strengthened controls for implant type, manufacturer, quantity, acquisition cost, procedure association, payer requirements, charge entry, claim reporting, contract treatment, and payment received.
Both professional and facility claims were monitored from charge completion through clearinghouse acceptance, payer receipt, adjudication, rejection, denial, payment, and final resolution.
Denials were reviewed at the encounter level and categorized by authorization, medical necessity, coding, modifier, site-of-service, eligibility, enrollment, documentation, bundling, implant reimbursement, contract configuration, and payer-processing issues.
Professional and facility payments were reviewed against expected reimbursement, contractual adjustments, patient responsibility, underpayments, implant provisions, multiple-procedure reductions, unapplied payments, and posting accuracy.
A unified reporting structure tracked authorization status, professional and facility charge status, claim status, denial status, payment status, implant status, outstanding balance, next action, and responsible owner.
The Result
The engagement connected professional and ambulatory surgery center billing processes that had previously operated independently.
The organization improved its ability to manage the complete financial lifecycle of each procedure, identify missing revenue earlier, prevent avoidable claim disruption, reconcile implant and supply charges, and monitor both claims through final resolution.
The practice gained a coordinated model for managing one clinical encounter across two distinct revenue cycles.
Professional and facility teams operated with shared procedure, authorization, and claim information.
Missing professional charges, facility charges, implants, supplies, and ancillary services were easier to identify.
Authorization, coding, documentation, and site-of-service discrepancies were identified earlier.
Leadership gained visibility into whether both claims were submitted, adjudicated, and paid correctly.
Outstanding professional and facility balances could be reviewed together at the procedure level.
Management gained a clearer view of total procedural revenue instead of evaluating each entity in isolation.
Why This Engagement Was Complex
Professional and ambulatory surgery center billing require different claim structures, coding rules, reimbursement methodologies, contracts, and compliance controls. The challenge was ensuring that both claims accurately represented the same clinical encounter while meeting the distinct requirements of the physician practice and facility.
GoHealthcare Leadership Perspective
A procedure is not financially complete when the patient leaves the ambulatory surgery center. It is complete when the professional and facility services have been accurately documented, coded, billed, adjudicated, reconciled, and resolved. Integration creates shared controls without erasing the distinct requirements of each entity.
Key Takeaways
About GoHealthcare Practice Solutions
GoHealthcare Practice Solutions provides operational and revenue cycle support for physician practices, ambulatory surgery centers, pain management, spine, orthopedics, neuromodulation, and other musculoskeletal specialties.
Professional and ambulatory surgery center billing, accounts receivable, denial management, and reimbursement oversight.
Specialty prior authorization and utilization-management workflows for complex procedures.
Charge reconciliation, coding and documentation review, implant oversight, payer strategy, and operational analytics.
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GoHealthcare Practice Solutions helps specialty practices and ambulatory surgery centers connect professional and facility billing, strengthen charge capture, reduce preventable denials, improve reimbursement visibility, and protect procedural revenue.
Contact GoHealthcare Practice SolutionsThis case study is presented for general informational and educational purposes. Client-identifying information has been removed or modified to protect confidentiality. Results vary based on organizational structure, payer contracts, procedure mix, documentation quality, coding accuracy, authorization requirements, billing systems, staffing, network participation, reimbursement methodology, and other factors.
GoHealthcare Practice Solutions does not guarantee payment, reimbursement, authorization, denial reversal, collection performance, or specific financial or operational outcomes. Clinical decisions remain the responsibility of licensed healthcare professionals. Coding, billing, authorization, and reimbursement decisions remain subject to applicable laws, regulations, payer policies, contracts, and documentation requirements.
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