The Hidden Reason Physician Groups Lose 1 in 8 Consult Claims

Independent surgical practices have historically lost roughly 1 in 8 interprofessional consult claims, not to clinical criteria, but to documentation gaps between the consult and the billing desk. Dr. Kevin Halow explains where that loss actually happens.

Dr. Kevin Halow MD, MBA, surgeon, veteran, and Chief Medical Officer of ClinicianCore, unpacks a statistic that has stayed with him: roughly 1 in 8 interprofessional consult claims at independent surgical practices are lost, not because the consult didn't happen, but because the documentation trail broke down somewhere between the phone call and the billing desk. Drawing on a real co-surgery case and lessons from military trauma care, Dr. Halow explains why hand-off discipline, not clinical error, is the real driver behind denied consult claims, and what changes when every step of a consult is captured and routed automatically.

About the ClinicianCore Podcast

Hosted by Dr. Kevin Halow, the ClinicianCore Podcast explores unified clinical communication, physician burnout reduction, HIPAA-compliant collaboration, and the real impact of AI in healthcare.

New episodes are released every Monday at 1 PM EST.

If you’re a healthcare leader, physician, administrator, or innovator committed to improving clinical efficiency and restoring clarity to care delivery, this podcast is for you.

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Learn more about ClinicianCore and our mission to strengthen clinician collaboration at:
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LinkedIn: https://www.linkedin.com/in/kevin-halow-md/

Transcript

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My team and I were discussing another article on the difficulties with physician reimbursement. Here is a statistic that stuck with me. One in eight. That is how many physician consult claims many practices are losing. It's not because the consult did not meet criteria or the consult didn't happen, but because somewhere between the phone call and the billing desk, the paperwork fell apart. Hello again. Welcome back to the Connected Practice, a Clinician Corps series of podcasts. I'm Dr. Kevin Hallow, surgeon, veteran, co-founder, and chief medical officer of Clinician Corps. In today's podcast, we're going to dive into that statistic one and eight. We're going to think about that in terms of your own patient volume and to discuss why this is real revenue that you are missing. It is a statistic that insurance companies love because they and their shareholders are getting free labor from you. On the other hand, for you, it's just more work that you've done and intellectual wealth that once again, you're giving away with nothing in return. I have spent most of my career split between different identities: a surgeon, an officer, and a small business owner. As part of my duties, I have also had to spend time on claim denials, which is not what I signed up for in medical school. But here's what 27 years in the operating room and the office has taught me. The clinical work isn't always the problem. The problem can be everything around it. You see, a consult happens. A specialist calls back with clearance. A note gets dictated. And then that note has to survive this crazy relay race through a scheduler, through a biller, through a coder, through a payer's own internal review before anyone gets paid for the work that has already happened. And if one runner in that relay race drops the baton, the claim doesn't just get delayed, it gets denied. And a denied consult claim doesn't usually get revisited. Gets written off quietly months later by someone who wasn't even in the room when the consult happened. That's the hidden part. It's not a dramatic failure. It's a number of small individual handoffs, and the one in eight is just what happens when enough of them slip by. I was trained to be self-reliant. You're taught over and over that the decision is yours and the outcome is yours. Yeah, there's some truth in that. But it's not quite accurate because there's never been a time that I fixed a patient by myself. I've always had a team. For example, in the military, a trauma case wasn't one surgeon being a hero. It was a handoff. From the medic in the field to the team that stabilized the patient, to me and the team and the trauma bay and the operating room to the nurses in recovery in the ICU. Every one of those handoffs had to be clean or the whole chain broke down. The handoffs themselves were as important as the surgeries. I carried that into civilian practice, and honestly, it took me a while to notice that most independent practices don't emphasize that handoff at all. We concentrate on the diagnosis and the surgery. But is anyone really triple checking that fax or the callback that never comes? The same profession that demands surgical precision can let a consult note sit in the queue for four days and not think that that could be a problem. Let me give you the version of this that I have actually lived, both on the surgery side and the administrative side. So one of the neurosurgeons asked me to do a co-surgery with her, an L5S1 anterior lombar and body fusion. That is a lot of coordination. Both my office staff and hers needed to get the pre-authorization done, the schedule's coordinated, and the patient on the schedule. In addition, the patient needs medical clearance from the patient's primary care physician, the anesthesiologist needs the patient's full medication lists, and finally, the operating room needs a scheduled date and time. In the old workflow, that is countless phone calls, emails, faxes, and communications across different EMR systems. All of that information may or may not land despite the surgery schedule's persistent calling to check and see if anything moved. Often it takes one bottleneck. For example, if the primary care office is behind because they're swamped, no one in the practice even knows that there's a problem until the day before surgery. This is just not a paperwork issue anymore. It's a canceled OR slot. A patient took the day off of work for nothing, two surgeons who have both of their busy schedules disrupted, and many different staff members spending a full day untangling a mess that a shared, trusted channel would have flagged four days earlier. That's the pattern behind the one in eight number two. It's the same miss handoff, just wearing a billing code instead of a surgery schedule. So what can change all this? What eliminates that one and eight loss? Well, here's a thought. How about make it automatic? Once the consult request, the specialist response, and the timestamp on every step is captured automatically in one shared record, the billing team has everything they need to send a clean claim the first time. Not eventually, but on the first pass. That's not a billing fix, that's a communication fix that happens to show up on a billing statement. When every consult is verified, routed to the right queue, and documented the moment it happens, you stop reconstructing what happened three weeks later for memory and sticky notes. You already have the record. There's fewer denies, fewer appeals, and physicians that stopped getting pulled back into billing disputes for patients. They treated months ago. My co-founder and I did not build Clinician Corps because we wanted to think about consult claims. We built it because I was tired of watching good clinical work get lost in a handoff that no one was actually watching. Clinician Corps' HCO practice HQ exists so that every consult, the request, the response, the record, lives in one trusted place from the moment it starts to the moment it's billed. If your practice has a number like one in eight or worse, sitting somewhere in your billing reports, it's not a staffing problem, it's a handoff problem. And handoffs, I promise you, are fixable. If you're ready to see how Clinician Core's HCO practice HQ can revolutionize your billing and coding department, come check it out at cliniciancore.com. While you're there, sign up for our wait list for our upcoming September release. You can also check out our many podcasts, webinars, blogs, and white papers. I'm Dr. Kevin Hallow, co founder and chief medical officer of Clinician Core. It's time to start making the insurance companies pay for the services that you provide so well. Thanks for listening.