Specialty
Family Practice Billing
Family practice sees the widest mix of ages, plans and visit types of any outpatient specialty, and that breadth is precisely what makes its billing error-prone.
What makes it different
The things that decide whether these claims get paid.
- Every payer type, all the time
- Commercial, Medicare, Medicaid and self-pay in a single day, each with different eligibility rules, preventive schedules and documentation expectations. The variety is the difficulty.
- Preventive care schedules differ by plan and age
- What is covered as preventive, how often, and for which age band varies between payers. A screening billed outside the covered interval is denied, and the patient is rarely expecting the bill.
- Immunisations have two components
- The vaccine product and its administration are billed separately. Missing the administration component is one of the quietest and most repeatable losses in the specialty.
- Same-day acute and preventive visits
- Common in family practice and legitimately billable together, but only where documentation distinguishes the two clearly.
Where the money goes
Four leaks specific to Family Practice.
A healthy practice in this specialty collects around 96% of billed charges. Most of the gap below that is made up of these.
- Immunisation administration billed without the product, or the reverse
- Preventive services delivered outside a plan's covered interval
- Eligibility not rechecked when family coverage changes mid-year
- Same-day acute and preventive care collapsed into one code
| Measure | Result | Reference |
|---|---|---|
| Collection rate | 96.0%OK | > 95% |
| Days in A/R | 28OK | < 30 |
| Denial rate | 3.0%OK | < 5% |
| A/R over 90 days | 8.0%OK | < 10% |
Illustrative figures — not a client result.
Questions
Asked most often.
Why is eligibility harder in family practice?
Because coverage changes more often. Children age off plans, families change employers, and Medicaid redeterminations move people in and out. A verification taken at registration is stale faster here than elsewhere.
Are well-child visits a common source of denials?
Yes, usually on interval rather than on merit — the visit was legitimate but fell outside the plan's covered schedule. Checking the schedule at booking prevents nearly all of it.