A continuing revenue-cycle improvement initiative with a multispecialty medical group of approximately 150 providers.
The Challenge
A successful multispecialty medical group with approximately 150 providers had a backlog of more than 10,000 rejected and denied claims. Those claims and the problems behind them were already present when the engagement with The Valletta Group began. Enrollment requirements differed for each provider depending on location, specialty, and insurance payer. Delayed enrollment, coding discrepancies, and inconsistent reimbursement procedures created substantial financial exposure.
More billing staff alone would not have answered the practice’s real questions: why claims were being denied, and how to keep the same problems from recurring.
Finding the Root Causes
The Valletta Group analyzed the denials by provider, payer, location, date of service, coding issue, and financial exposure.
The largest recurring problem was incomplete provider enrollment. The analysis showed which providers were affected, which payers were responsible, and where potentially recoverable revenue was concentrated.
In this engagement, the practice retained responsibility for enrollment. Valletta supplied the information it needed to prioritize corrective action.
The analysis also uncovered payer-specific coding denials. Working through these with the practice’s staff helped separate coding errors from coverage restrictions and enrollment deficiencies.
Thousands of individual claim denials were symptoms of a smaller number of recurring operational problems. Identifying those problems made corrective action measurable and manageable.
Modernizing Payment Workflows
Valletta identified opportunities to replace paper checks and manual remittance processing with electronic funds transfer (EFT) and electronic remittance advice (ERA). Working with Valletta, the practice reached approximately 95% electronic payments and remittances. For comparison, the 2025 CAQH Index, a national survey of health plans and providers, reports fully electronic adoption across the medical industry of 78 percent for claim payment and 87 percent for remittance advice.2
Based on Valletta’s experience with other practices, manual processing takes considerably longer than electronic processing. The transition gave the practice the opportunity to redirect staff toward more valuable revenue-cycle work.
Identifying Changes in Payer Behavior
Valletta also discovered that certain insurers had substantially curtailed or discontinued previously established out-of-network reimbursement. These changes had not been fully recognized internally. Once the altered payment patterns were identified, leadership could reconsider whether continuing to treat patients under the affected out-of-network arrangements still made financial sense.
Working Around Software Limitations
The practice’s management software complicated self-pay balances, patient statements, and patient payment posting. Instead of waiting for vendor updates, Valletta and the practice established workable procedures using the existing technology, which allowed patient billing and collection to continue more efficiently.
“
Valletta and the practice established workable procedures using the existing technology.
Where Things Stand
This case study covers two years of work, and the engagement is continuing.
Payer responsibilities have been reorganized, and claims management that was once reactive is now prioritized by financial impact. The practice also added staff to its credentialing team and now orders that team’s work by its effect on collections.
Credentialing will keep needing attention. The group is growing and continues to add providers, and each new provider has to be credentialed and enrolled correctly with each payer, so this is continuing work rather than a one-time fix.
Every practice is different, and results will vary. What carries over is the method:
The Valletta Group can help your practice find out what is behind its denials.
Sources
- 42 CFR § 424.521(a), Request for payment by physicians and other suppliers. A separate 90-day window applies to Presidentially declared disasters.
- CAQH. 2025 CAQH Index Report: Executive Report, Medical Plan Adoption of Fully Electronic Administrative Transactions.
This case study describes one engagement and does not identify the client. Results vary by practice. Revenue identified for recovery is not a guarantee of payment.
