A Kentucky behavioral health provider specializing in mental health services for TRP and IOP programs. Small team, high volume of group sessions and assessments, and a billing operation that had grown faster than its knowledge.
Denials were eating cash flow. The provider was self-billing and didn’t know why claims kept bouncing. Three problems were driving most of it: modifier sequencing — not knowing when to lead with the rendering provider’s credential versus the program modifier — inaccurate or missing taxonomy codes, and no understanding of bundling rules for group sessions and overlapping assessments.
We took over the full revenue cycle and started with diagnostics, not cleanup. We audited their EMR configuration and clearinghouse settings before touching a single claim. What we found: the modifier logic was wrong at the source, taxonomy codes were missing or mismatched, and group session and assessment claims were being bundled incorrectly — which meant denials weren’t a billing problem, they were a configuration problem.
Modifier sequencing corrected, taxonomy codes fixed, bundling rules applied properly. Denials dropped from roughly 30% to under 12%, aged receivables were collected, and the fix was permanent — the next batch of claims didn’t come back denied the same way.
“We’d been drowning in denials all year and had no idea why. When Capture RCM Operations came in, they didn’t just take over our billing — they came on site and worked side by side with me, my leadership team, and the staff who actually touch the claims every day. They sat with us, walked through our EMR, and showed us exactly where the modifier sequencing was wrong, where taxonomy codes were missing, and why our group sessions kept getting bundled incorrectly. For the first time, someone explained it in plain English instead of just resubmitting the same claims. Within a few months our denials dropped from 30% to under 12%, and we finally had cash flow we could count on. I wish we’d called them sooner.”
Schedule a free audit of your EMR and clearinghouse settings.
A South Carolina behavioral health provider running PHP and IOP programs. Clinical staff were strong, but their documentation wasn’t carrying the weight of the clinical work.
Patients were being authorized for less time than they clinically needed. Prior authorizations and concurrent reviews were cut short or denied for lack of medical necessity — not because the care wasn’t necessary, but because the paperwork didn’t prove it. Treatment plans were thin, progress notes didn’t connect symptoms to services, and the team didn’t know what payers were actually looking for.
Our utilization review team worked directly with their clinical staff. We showed them exactly what was missing in their documentation — down to the treatment plans and the clinical detail that justifies each service and each additional day of care. It wasn’t about writing more; it was about writing what the payer needs to see. Beyond documentation, we coached their medical and clinical providers on how to run successful peer-to-peer reviews — how to communicate the right clinical information to the payer’s reviewer so the authorization gets approved on the call instead of denied and appealed later.
The clinical team’s documentation now supports the level and length of care they provide. Authorizations and concurrent reviews are approved for more days, patients stay in treatment for the time they clinically need, and peer-to-peer reviews are winning on the first call — cutting the time and cost of the appeal process.
“Our clinicians knew the patients better than anyone. They just didn’t know how to show it on paper. When Capture RCM Operations came in, they walked us through it step by step, and now our treatment plans actually support the care we’re providing.”
Our UR team can audit your documentation and show you exactly where the gaps are.
