Their EHR Was Configured for 2021. Their Payers Were Operating in 2024. The Gap cost $94,000.
Table of Contents
THE SITUATION
This telehealth counseling practice launched in 2021 during peak COVID demand. They built everything inside TherapyNotes intake forms, scheduling, billing templates, and claim submission. It worked well in 2021 because every payer was accepting telehealth under emergency flexibilities.
Those flexibilities ended. Payer rules changed. TherapyNotes got updates. The practice’s billing configuration did not.
By mid-2023, they were submitting nearly 1,400 claims per month across three states and nine providers. Collections weren’t matching the volume. Their internal billing lead assumed it was a payer mix issue. It wasn’t.
WHAT WAS ACTUALLY WRONG
We audited six months of claims across all three states. The problems were systematic, not random.
Wrong place-of-service codes on all telehealth claims. Post-PHE, Cigna and BCBS both required POS code 10 (telehealth provided in the patient’s home) instead of POS 02. Every claim to these payers was rejected at adjudication. The practice had been resubmitting the same wrong code, getting the same denial, and assuming payer error.
Modifier 95 is missing on Medicaid claims in two states. Texas and North Carolina Medicaid both require Modifier 95 on audio-visual telehealth claims starting January 2023. The TherapyNotes template had not been updated. Fourteen months of claims to TX and NC Medicaid had been submitted without it.
Session duration codes do not match the documentation. Providers were documenting 53-minute sessions, which were billed as 90837, but the default billing template was submitting 90834 (45-minute code). The difference in reimbursement is $38–$55 per session, depending on the payer.
None of this was TherapyNotes’ fault. The templates are configurable. Nobody had configured them.
WHAT WE DID
Week 1: Full EHR billing audit exported 6 months of claims, cross-referenced against payer contracts and EOBs. Mapped every denial code to a specific template or configuration error.
Week 2: Rebuilt all billing templates inside TherapyNotes. Updated POS codes per payer, added Modifier 95 to all applicable state Medicaid templates, and corrected CPT code defaults to match documentation standards.
Week 3: Filed corrected claims for all denials within the timely filing windows. Submitted Modifier 95 retroactive appeals to TX and NC Medicaid for the 14 months where the contract language supported it.
Ongoing: Set up a payer rule change monitoring process quarterly review of EOB patterns to catch configuration drift before it becomes a $90,000 problem.
THE RESULTS
| Metric | Before | After |
|---|---|---|
| First-Pass Acceptance | 58% | 93% |
| Monthly Collections | $61,000 | $77,000 |
| Telehealth Claim Denial Rate | 31% | 3% |
| Revenue Recovered (appeals) | — | $94,000 |
| Avg Claim Turnaround | 6–9 days | 48 hours |
TX and NC Medicaid approved $41,000 in retroactive appeals. Cigna and BCBS corrected claim batches recovered $53,000. Total recovery: $94,000 over 10 weeks.
Stop Losing Money On Claims!
Payer rules change yearly (and sometimes mid-year); if your EHR hasn’t been audited in 12 months, you’re likely losing revenue on every claim batch. One audit and reconfiguration delivers measurable recovery within 30 days.