Recovered $675,146 in Lost Revenue

In 2024, a gastroenterology group contacted us for billing assistance. The physicians were extremely frustrated, as they were continuously losing revenue and had lost confidence that their previous billing team could protect their income.

The group wanted assurance that we could manage billing for their physician practice, surgery center, anesthesia group, and laboratory while ensuring accurate reimbursement. From the start, we emphasized the importance of detailed documentation, including complete scope reports for colonoscopy, endoscopy, video capsule endoscopy, anesthesia records with provider details, and laboratory findings to support compliant billing and full allowable reimbursement.

The group’s biggest concern, however, was whether previously lost income could be recovered.

Background

Rather than making unrealistic guarantees, we explained our extensive experience recovering underpaid and denied claims. We committed to doing everything possible to pursue recovery while maintaining payer compliance and protecting the practice’s relationship with Anthem.

What followed was one of the most complex recovery efforts we have handled for a gastroenterology group.

The Challenges

During our audit, we identified 966 Anthem claims spanning 14 months that were either underpaid or denied. These included both surgery center claims and professional service claims.

The core issue stemmed from the Anthem contract structure:

• Anthem’s contract allowed one bundled payment per procedure
• The bundled rate included:
  • Surgery center payment
  • Physician professional services
• Anesthesia and laboratory services were paid separately

However, the previous billing company made several critical errors:

• Submitted two separate claims per procedure
  • One from the physician’s office
  • One from the surgery center
• Anthem paid only the lower professional component
• Surgery center claims were denied as “maximum payment made”
• In many cases, both claims were denied with no follow-up
• Rejected claims were billed directly to patients
• Underpaid claims were posted without appeal or correction

As frustration grew, physicians seriously considered leaving the Anthem network altogether.

FC Billing Strategy

We immediately implemented a structured, payer-focused recovery strategy designed to correct the billing structure and recover lost revenue while maintaining compliance.

Our approach included:

• Arranging Zoom meetings with Anthem case management
• Securing assignment of a dedicated Anthem case manager
• Preparing and submitting a detailed spreadsheet via secure email that included:
  • Patient information
  • Claim numbers
  • Status of each claim
  • Corrective actions taken

Problem Resolution

To align with Anthem’s contract rules, we:

• Voided previously submitted incorrect claims
• Resubmitted global bundled claims correctly from the surgery center
• Ensured claims followed Anthem’s bundled payment structure
• Documented every step, phone call, submission, and communication

The recovery process was not straightforward. Throughout the year:

• Anthem frequently requested revised submission formats
• Additional documentation was repeatedly requested
• Multiple explanation letters were required
• At several points, the process became so complex that submissions had to be restarted entirely

Despite these challenges, we continued working the claims aggressively for 12 full months.

Results

After a year of persistent and structured recovery work:

• All previously lost payments were recovered
• Anthem issued payments even months beyond normal filing limits
• Total revenue recovered: $675,146.08

Outcome

Because of our experience and commitment, this gastroenterology group:

• Recovered significant lost revenue
• Avoided unnecessary write-offs
• Regained confidence in their billing process
• Maintained their Anthem network participation instead of exiting the contract

Conclusion

This case study demonstrates the importance of deep payer knowledge, contract interpretation, and persistence in complex recovery situations. Through a structured approach and ongoing communication with Anthem, FC Billing helped this gastroenterology group recover a substantial amount of lost revenue without jeopardizing payer relationships.