As a patient’s first point of contact with the healthcare system, primary care practices have a lot on their plate. Delivering quality care is only part of the challenge.
Every patient encounter must be accurately documented, coded, and submitted for reimbursement. Even small errors along the way can delay payments or cost in terms of revenue.
The Centers for Medicare & Medicaid Services (CMS) reported a 10.3% improper payment rate for evaluation and management services in 2024. This percentage represented an estimated $3.9 billion. Incorrect coding and insufficient documentation were the leading sources of these improper payments.
Fortunately, many billing problems can be addressed before they become costly. This article explores four practical ways primary care practices can prevent common billing errors and protect their revenue.
Accurate billing always starts with a complete clinical record. Coders can only report diagnoses and services that the documentation supports. Any information that is missing or unclear would lead to coding errors, payment delays, or denials.
A 2026 report shared by Reuters discussed an external audit of UnitedHealth’s HouseCalls program. It was determined that 3.4% of diagnoses recorded during 2025 were not supported by patients’ medical records. The review also followed earlier concerns about inconsistent documentation practices.
Primary care practices can mitigate similar issues by ensuring each encounter documents the following:
Your team doesn’t need a long list of notes. However, before coding, a reviewer should be able to understand from the record what was treated, what was done, and why the reported codes are appropriate.
Adding or changing healthcare providers can cause billing issues if their credentials and enrollment details are not updated at the same time. This is especially important in primary care, where practices may work with physicians, nurse practitioners, and others whose qualifications and billing arrangements may differ.
Suppose a facility brings a family nurse practitioner (FNP) onto its team. The billing staff must know not only that a new provider has joined, but also what services they are qualified to provide. This is relevant since FNPs can take on a broad range of primary care responsibilities.
Carson-Newman University explains that their advanced preparation involves the application of advanced nursing theory in a wide range of care services for adults of all ages. That means the practice needs accurate information about the provider’s qualifications and role when setting up the administrative side of care.
For instance, a registered nurse pursuing an advanced practice role may complete a Master of Science in Nursing (MSN) with an FNP focus. An MSN-FNP online program can help with this preparation through a flexible mode of learning. Once that nurse joins a practice as an FNP, the educational pathway is only a part of the transition.
The practice must ensure that the provider’s current credentials, enrollment status, and billing details are properly reflected in its records and claims. As providers join, leave, or change roles, practices should review the following:
With accurate documentation, one part of getting the claim paid is accomplished. Still, primary care practices must ensure the codes are an accurate representation of the services provided. Plus, payer requirements, such as eligibility, referrals, and prior authorization, must be addressed before submission.
In its 2025 Prior Authorization Physician Survey of 1,000 practicing physicians, the American Medical Association (AMA) found something interesting. Physicians completed an average of 40 prior authorization requests every week. That consumed around 13 hours of both physician and staff time.
The issue went as far as how the requests were handled. Just 33% of physicians believed that the latest insurer pledge would make a meaningful difference. AMA President Bobby Mukkamala remarked, “Physicians are especially frustrated when so-called peer-to-peer reviews are conducted by individuals who lack the appropriate clinical expertise to evaluate a patient’s care.”
His solution for rebuilding trust included transparent and sustained actions that would streamline prior authorization. For primary care practices, it’s important to build payer checks into the claim process instead of waiting for an insurer to flag a problem. Teams must review as follows:
The reality is that despite stronger documentation and careful claim checks, certain claims will be denied. The important question is what happens after the denial. Instead of treating it as lost revenue, primary care practices can review the reason and correct eligible claims when the documentation supports payment.
A CBS News analysis of 1.3 billion federal health insurance claims found that insurers denied 19% of in-network claims in 2024. That would amount to roughly one in five. Yet, fewer than 1% of those denials resulted in an appeal, even though half of the appealed claims were ultimately successful.
This is further encouragement not to treat denials as a dead end. That’s because some denied claims may have recovery potential that stays unexplored simply because they are never challenged. Billing teams should consider every denial as an opportunity for deeper review, as follows:
The final step is to use those patterns to improve the earlier stages of billing. If claims repeatedly come back due to missing documentation, coding errors, or payer requirements, address those problems before the next claim is submitted.
Incomplete documentation, inaccurate coding, outdated provider information, eligibility issues, and authorization problems can all contribute to billing errors. Not only that, but these causes in turn lead to payment delays and claim denials.
Start by identifying the reason for denial and checking the supporting documents. Correct errors or provide missing information when permitted, appeal appropriate denials, and track recurring issues to prevent similar problems in future claims.
Practices can strengthen documentation, keep provider and enrollment details current, and review denials systematically. Together, these steps can reduce avoidable rework and help practices recover/retain more earned revenue.
Billing Area | Key Action |
Documentation | Document each encounter completely. |
Provider details | Keep credentials and enrollment current. |
Claim submission | Verify codes and payer requirements. |
Denial management | Correct, appeal, and track denials. |
Revenue protection | Use billing data to prevent recurring errors. |
While it is true that primary care practices cannot control every payer decision or reimbursement challenge, they can prepare their billing processes. Since operating costs continue to put pressure on medical teams, it’s crucial to protect revenue.
Medical Group Management Association (MGMA) reported in 2026 that 84% of medical groups had higher year-to-date costs than the previous year. Just 47% reported higher revenue. The organization also identified better coding accuracy and provider documentation among the revenue-cycle improvements being used for better financial performance.
The four steps in this article, when combined, can help create a billing process that is proactive. This means each claim can be as accurate, complete, and defensible as possible. Not only will primary care practices reduce administrative work, but they will also retain more of the revenue.
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