The situation
High-cost biologic claims were submitted with mismatched units and incomplete authorization references, creating avoidable medical-necessity and quantity denials.
Two providers had changed locations without complete payer roster updates, so otherwise clean claims were rejecting at enrollment validation.
What we did
- 01
We matched every active infusion authorization to drug, units, dates and rendering provider before the appointment date.
- 02
Coding review reconciled J-code units against administered quantities and clinical documentation before submission.
- 03
Credentialing specialists corrected payer rosters while billers held and released affected claims inside each retroactive window.
- 04
A daily high-dollar work queue kept every unresolved infusion claim visible to an assigned owner.
The result
- — $428K in delayed and denied infusion revenue was collected within five months.
- — Infusion-related denials fell 61%, with first-pass acceptance reaching 99.1%.
- — The practice gained a single authorization-to-payment workflow shared by clinical and billing teams.
"We finally had one view from the authorization through the payment, instead of three teams working from different lists."