Everyone at your practice wants claims to be paid quickly. When delays occur, attention often turns to the billing team for a solution, which makes sense — until you realize what pediatric billers are up against. Payors change requirements and policies, claims get stuck waiting for information, and contacting payors for help is a painstaking process even the most patient biller would rather avoid.
With the right support from fellow billers, billing experts, and your practice team, billers can build workflows that work with them, and work smarter (instead of harder) with tools that actually help.
In this post, we’ll cover some common reasons billers might get stuck, why these friction points occur, and how your practice can help create an environment where billers can thrive.
Pediatric Billing’s Unique Challenges
Pediatric billing has complications that other specialties may not encounter in quite the same way. Vaccines are a good example. Practices must account for both the vaccine product and administration codes, and requirements for how these codes appear on the claim can vary by payor. That means a workflow that gets one claim paid may not work for another under a different payor.
Then there are situations that seem simple until they aren't. Twins, for example, are not duplicate patients, despite the same birth date and often identical dates of service. Payors may reject these claims as duplicates despite careful attention to detail. A practice's billing team has to navigate the nuances of pediatric care while also keeping up with all the other changes affecting medical billing. The combination makes pediatric billing particularly dependent on careful workflows, good communication, and experienced problem solving.
Shifting Payor Rules: A Moving Target
A billing team can have a well-established workflow for one payor, only to discover that another has completely different requirements. Some of these requirements can be obscure: A claim’s acceptance might depend on a particular modifier combination, the practice's CLIA certification level, payor-specific formatting, or documentation requirements that aren't immediately obvious.
That doesn't mean billers are sending claims in error, or without due diligence. When rules shift frequently, billers must iterate and adapt in real time.
Crowdsource Billing Knowledge
Often, an experienced biller can recognize patterns with particular payors rejecting specific claims. Making note of this pattern and sharing these observations with other billers can help the team rise above payor obfuscation.
That's one reason billing community gatherings like PCC’s Billing Drop-In are so valuable. The daily, weekly, and yearly puzzle of getting claims paid is easier to solve when billers don't have to solve every piece of it alone.
Clinicians: Strengthen Documentation
Clinicians can help billers navigate payor rules, too. Strong documentation gives billers a better foundation for submitting claims and responding to questions from payors.
For example, documenting the total time spent before, during, and after a visit can support accurate leveling of the visit using medical decision making (MDM). Without sufficient documentation, an auditor may determine that a lower level is appropriate. This can result in a clinician’s visits being paid insufficiently for the level of care delivered, which can have significant revenue consequences over the long term.
Explore Coding Tools & Support
PCC's 2025 E&M Coding Tool can help clinicians understand MDM leveling and the documentation that supports it. As PCC’s coding expert Brian Kennedy explains, when documentation clearly supports the level selected, clinicians and billers can feel more confident sending the claim out, reducing concerns that the coding won't hold up.
PCC clients have access to the AAP Coding Newsletter as part of their PCC Care Plan. If you have a particularly thorny coding question, PCC's experts are available to help. Just reach out to support@pcc.com.
The more clearly the clinical and billing sides of the practice communicate, the less time billers are required to spend untangling preventable problems, which saves practices time and money.
Inefficient Workflows Waste Time & Energy
Billers are great detectives. However, sometimes too much of a biller's time can disappear into information gathering instead of “solving the case.” Something as straightforward as checking claim status can become arduous when it requires logging into a specific payor’s portal system. It is simple the first time, but inefficient when required many times per day. When billers are bogged down with repetitive tasks, they’re prevented from doing the higher-value work of analyzing and resolving problems so that claims get paid.
Front Desk: Update Now, Not Later
Some billing problems actually begin well before a claim reaches the billing office. Consider insurance information collected at the front desk: If a patient's insurance information is incomplete or incorrect at check-in, a biller will eventually have to track down the missing information and correct the claim.
As PCC billing expert Ben Brandt put it, "Updating insurance information later is like taking cash from a customer and deciding to put it in the cash register sometime this afternoon." Without insurance information that’s accurate, the claim cannot be paid. The always-busy front staff can feel implicit pressure to hurry things along when a family is waiting on them, but taking the time to update demographics and insurance information in real time will help create a smoother billing cycle for the practice and families alike.
Use Your Full Toolkit
Automation and good workflow tools can make a meaningful difference. PCC's Real-Time Claim Status (RTCS), for example, can reduce the need to manually check claim status across payor websites. PCC’s Electronic Data Interchange (EDI) team can also investigate connectivity with smaller payors when needed and establish connectivity where possible.
Interactive worklists can help, too. Tools such as the Insurance Balances Tool and Personal Balances Tool give billers a way to organize and prioritize the balances that need their attention while connecting with payors and families as needed.
Lack of Visibility Limits Effective Communication
Sometimes the thing keeping a biller stuck isn't a payor or a software tool. It's the difficulty of getting the rest of the practice to see what's happening and understand the broader implications lying under the surface of metrics like A/R days.
PCC billing expert Jeremy Hill has plenty of experience in training billers on-site and remotely, and has witnessed that billers who are struggling may hesitate to ask for help. Billers may know exactly where a workflow is breaking down, but bringing that problem to a physician or practice owner can be difficult, particularly if previous attempts to raise concerns have been dismissed.
Focus on Shared Goals
Billers can find themselves in a tough spot when it comes to communicating their needs. Great communication can happen when tough topics are approached with curiosity. After all, everyone at the practice has similar goals: to reduce friction, improve workflows, support their colleagues and ultimately, serve the patients.
A biller who says, "This is making my job harder" may not be heard the same way as one who offers, "This workflow is creating a delay in the revenue cycle." Billers, practice owners, and office managers have several options to open doors for better communication — that's one place where PCC's in-person training can help.
PCC Advocates For Billers, Physicians, and Practices
An on-site trainer like Jeremy can observe how a practice actually works, then help the team update their workflows and identify opportunities from a fresh perspective. Sometimes the solution is technological. Sometimes it's a workflow change. And sometimes it's as simple as making sure a biller has the equipment they need, such as a second monitor or an updated keyboard to make switching between tasks easier.
On-site training can also give billers an advocate when there's a problem that is difficult to explain or discuss internally. Jeremy shares one example involving a biller who inherited a practice with months of unpaid claims.
At first glance, it appeared like the claims simply hadn't been worked. The metrics on the practice’s financial Dashboard were “alarming,” triggering a discussion with the practice owner. Jeremy sat down with the owner and biller, where the three of them discovered the underlying problem: payment posting.
All along, the claims had been being worked. It turned out that along with inheriting a billing role with a significant backlog, the practice operated under a capitation model, and the biller was struggling with the workflow for posting payments. Once the underlying problem was identified, Jeremy could suggest a workflow that helped the biller and the practice move from frustration and blame toward problem solving and resolution.
It can be difficult to solve some billing problems without help. PCC is a proud partner of practices who want to dig deeper. Experts like Jeremy can help you identify problems you might not have even been aware of, and act as objective third-party advocates for billers, physicians, staff, and practice owners. Along with on-site training for billers new to PCC EHR, we support practices with ongoing training, advocacy, and support.
Want to learn more about the ways PCC can support your entire practice? Reach out to us.
Transitions Can Be Frustrating
Transitions can be particularly difficult for billers because changes that seem straightforward from the outside can fundamentally alter how they do their jobs. This is especially true when a practice selects a new EHR.
A biller may have spent years developing efficient workflows on their previous system, learning the quirks, and building muscle memory for everyday tasks. Suddenly, relearning those same tasks in a new system takes longer. Familiar information is somewhere else. A process that used to take three clicks takes seven.
That doesn't necessarily mean the biller is bad at the new software. In fact, Jeremy points out, “Billers can be especially frustrated [during software transitions] precisely because they're good at their jobs. They're accustomed to moving fast, and they notice immediately when a new system slows them down.”
Trust Billers’ Expertise
One of Jeremy’s most important pieces of advice for a biller who is frustrated at learning a new workflow, system, or software is that a learning curve doesn’t indicate failure. He also recommends that billing teams acknowledge all of the things the billers are already excelling at, and celebrate the small wins as the team adapts to change.
During any professional transition, practices can help facilitate communication by setting realistic expectations, giving billers time to learn, and creating opportunities to ask questions without judgment.
PCC can help with that process, too. Our training expertise provides an objective third party who can help establish expectations, identify the learning curve, and support billers in the things they're already doing well. The goal isn't simply to teach someone how to use new software. It's to allow an experienced billing professional to play a key role in the entire practice’s evolution. Change is hard, but collaboration and understanding can help make it easier for everyone.
Other transitions can be more difficult to parse as industry and technology trends shift over time. AI is one example. PCC’s take? Billing expertise is more necessary than ever.
It's tempting to imagine a future where billing can happen without human intervention. You may have already seen an ad for a product or service that claims they can “automatically” complete your billing without any human intervention. But according to PCC’s Ben Brandt, AI billing tools that claim human billers won't be necessary are probably overstating what the technology can do. Why? Because the payors are using automation, too.
If a billing system uses AI to submit and work claims while a payor uses AI to evaluate those claims, the remaining problems don't necessarily disappear. They may simply become different problems — ones that still require a human to investigate, appeal, edit, and resubmit a claim.
“And,” Ben continues, “Even if 90% or 95% of claims eventually get paid automatically, that remaining 5% or 10% can still represent hundreds of claims every month.”
Someone needs to figure out why those claims didn't go through. That's where billing expertise becomes more important, not less.
The future of billing isn't necessarily one where billers disappear. It may be one where technology handles more of the repetitive work so billers can spend more of their time doing what they're uniquely good at: recognizing patterns, investigating exceptions, communicating with payors and practices, and being excellent detectives.
Tap into the Billing Community
A strong billing community gives professionals a place to compare experiences, crowdsource solutions, and learn from problems other practices have already encountered. PCC's Billing Drop-In sessions, the PCC Users' Conference, the AAP Coding Newsletter, and PCC's on-site and online trainings provide opportunities for billers to learn from one another and from billing experts.
Coding and billing don't always agree 100% of the time, either. Having access to people who understand both sides of the equation can help practices navigate those gray areas with more confidence.
The more connected billers are to their peers and to the experts who support them, the more resources they have when the next strange denial, unexpected payor requirement, or unfamiliar workflow problem lands on their desk.
Help Your Billers Get Unstuck
When billers have access to the support they need to thrive, the entire practice benefits, and your revenue cycle gets that much easier to manage. Where does it begin? Collaboration and care. It’s a value PCC shares with pediatric practices, who know that success begins with care.
As Ben Brandt puts it, “Care is a two-way street. The relationships we form with billers means that we have people out there that are not coworkers that care about us as well. That facilitates a positive cycle of feedback. Billers are directly involved with the design process [of PCC EHR]. We’re involving them directly so that we can provide the software they actually need.”
The revenue cycle starts before a claim ever reaches the billing office. Clear financial policies, accurate insurance information, good clinical documentation, and effective communication all contribute to getting claims paid.
In other words, getting your billers unstuck isn't just about helping the billing department. It's about helping the whole practice work together.
If you'd like to learn more about how your practice can build stronger revenue cycle workflows, check out our posts on financial policies and why the revenue cycle starts with hello. And if your billing team is running into a problem you can't quite solve, PCC is here to help.
Want to learn more about partnering with PCC? We’d love to speak with you. Reach out to learn more about all the ways that PCC is your partner in pediatric excellence.
