Introduction
For healthcare providers in Maryland, managing the business side of medicine has become just as critical as delivering quality care. With rising administrative burdens, increasing payer scrutiny, and patient cost sensitivity, clinics across the state—from solo practitioners in Annapolis to multi-specialty clinics in Baltimore—are under pressure to reduce claim denials and boost collections. But how?
The answer lies in adopting a proactive, data-informed revenue cycle strategy tailored to Maryland’s payer landscape. This article offers practical, proven steps that local providers can implement immediately—without needing to overhaul their entire practice.
Understanding the True Cost of Denials
Why Denials Hurt More Than You Think
Claim denials aren’t just a nuisance—they’re a financial and operational drain. Each denied claim costs an average of $25–$30 to rework. Multiply that by dozens (or even hundreds) of claims per month, and the revenue loss becomes significant. According to MGMA, approximately 65% of denied claims are never reworked, meaning lost income.
In Maryland, where Medicaid Managed Care Organizations (MCOs) like Amerigroup, Priority Partners, and Maryland Physicians Care dominate the landscape, even small eligibility errors or missing authorizations can cause claims to be rejected.
Maryland-Specific Denial Trends
- Pre-Authorization Lapses: Especially in behavioral health and chiropractic care, missing or expired authorizations result in frequent denials.
- Incorrect Payer Routing: Medicaid plans often switch MCOs. A patient listed under Amerigroup last month may now be covered by UnitedHealthcare, leading to a mismatch in payer ID submission.
- Duplicate or Timely Filing Denials: Maryland’s short filing windows for certain payers (e.g., 90 days from DOS) make delays risky.
- Coding Inconsistencies: Payers like CareFirst or Aetna are quick to deny mismatched CPT/ICD-10 codes or missing modifiers.
Root Causes of Denials—and How to Prevent Them
1. Implement Real-Time Insurance Verification
Problem: Patients often present outdated or inaccurate insurance information.
Solution: Use real-time eligibility tools (integrated with your EHR or practice management system) to confirm plan type, deductible, and active coverage on every visit. Train your front desk staff to catch red flags like plan changes or coverage lapses.
Pro tip: For Medicaid patients, check Maryland Health Connection or payer-specific portals to avoid routing errors.
2. Tighten Pre-Authorization Processes
Problem: Authorizations are missing, expired, or don’t match the service performed.
Solution: Maintain a centralized pre-auth tracking system—this could be as simple as a shared Excel sheet or as advanced as an integrated module in your PM software. List payer-specific requirements for common services. For example:
- Mental Health (CPT 90837): Requires auth after 8 sessions with most MCOs
- PT/OT: Requires new auth every 30 days
- Chiropractic (98940-98942): Strict visit limits and medical necessity forms
Assign one person or vendor to own the pre-auth process to eliminate gaps.
3. Code Accurately and Completely
Problem: Mismatched diagnosis and procedure codes, or missing modifiers.
Solution: Ensure your billing staff or partner stays current on:
- NCCI edits for Maryland Medicaid
- Correct use of modifiers -25, -59, -XU
- Linking appropriate ICD-10 codes to CPTs for medical necessity
Example: A visit billed as 99214 with a 90833 (psychotherapy add-on) without modifier -25 on the E/M code will likely be denied.
4. Customize Clearinghouse Edits
Problem: Claims with errors are submitted, rejected, and returned for correction.
Solution: Set up custom rules in your clearinghouse (e.g., Office Ally, Availity, or Change Healthcare) to flag errors before claims go out. Some examples:
- Missing referring provider for DME
- Invalid NPI combinations
- Missing place of service codes for telehealth claims
These pre-submission checks save time and reduce rework.
Increasing Collections: Best Practices That Actually Work
1. Speed Up the A/R Cycle
Step 1: Submit clean claims within 24–48 hours of service.
Step 2: Set follow-up benchmarks. For example:
- Commercial payers: Follow up if no payment by day 21
- Medicaid MCOs: Follow up by day 30
Use automated reminders and batch claim status checks to track claim status in real time.
2. Strengthen Patient Collections
With rising deductibles, collecting from patients is now just as important as collecting from payers.
Best practices for Maryland clinics:
- Offer payment plans for balances over $200
- Use text/email reminders to notify patients before mailing statements
- Collect credit card on-file agreements for high-volume patients
3. Avoid Common Write-Off Traps
Too many clinics write off balances that could be collected with one extra step. Avoid automatic write-offs unless:
- The balance is under $10 and collection costs exceed the recovery
- Payer adjustment codes specifically restrict rebilling
Real-World Case Example
Clinic: Small internal medicine group in Columbia, MD
Challenge: Denials for missing pre-auths, timely filing issues, and inconsistent coding
Solution:
- Integrated eligibility and pre-auth tool
- Created a denial tracking dashboard
- Outsourced coding to a Maryland-specific RCM vendor
Result: 34% reduction in denials and a 19% increase in net collections over 6 months.
Key Metrics to Monitor in Your Practice
KPIBenchmark
Clean Claim Rate 95% or higher
First-Pass Resolution Rate 85% or higher
Denial Rate Below 5%
A/R over 90 Days Below 15% of total A/R
Patient Collection Rate 85%+ of patient-responsible balance
Regularly review these numbers monthly and adjust strategies accordingly.
How to Train Staff Without Overwhelming Them
- Host monthly billing reviews to go over the top 5 denials
- Send out payer update emails—especially during policy changes (e.g., MCO annual updates)
- Create short video SOPs for the front desk and billing team on workflows like insurance verification or coding updates
Empowered staff = fewer errors = better revenue outcomes.
Final Thoughts: Maryland Providers Can’t Afford to Ignore Denials
Denials are not just a billing issue—they’re a clinical operations issue, a patient satisfaction issue, and a revenue issue. In Maryland’s uniquely regulated and payer-diverse market, clinics that take a proactive, data-driven approach to revenue cycle management will be best positioned for stability and growth.
You don’t have to solve everything overnight. Start by fixing the top 3 reasons for denials in your clinic, standardize those workflows, and then scale improvements.
FAQs
1. What is the average denial rate for medical claims in Maryland?
The industry benchmark is under 5%, but many Maryland clinics experience rates of 8–10% due to local Medicaid complexities and pre-auth issues.
2. How can I reduce denials from Medicaid MCOs in Maryland?
Start by verifying eligibility before every visit, track authorizations closely, and follow each MCO’s submission rules. Keep payer-specific cheat sheets for front office and billers.
3. What are the best tools for improving collections in small clinics?
Look for an EHR-integrated billing solution with automated patient statements, text reminders, and real-time eligibility verification. Many practices in Maryland use Kareo, AdvancedMD, or DrChrono.
4. Should I outsource billing or keep it in-house?
It depends on volume and complexity. Outsourcing to a team familiar with Maryland billing rules can often reduce errors and improve collections, especially for multi-specialty or high-volume clinics.
5. What’s the most common reason for denied claims in Maryland?
Missing or invalid prior authorizations, especially for Medicaid MCOs, is the leading cause. Close second: eligibility issues and incorrect coding.
