The Ultimate Pediatric Billing Guide for Busy Practices

Before You Start: The Hidden Impact of Billing Inefficiencies

Running a pediatric practice is deeply meaningful work, but when billing isn’t working smoothly, it quietly slows you down. Billing challenges like complicated codes, changing insurance requirements, and unresolved denials add up quickly. 

At Altus, we understand how billing issues take a toll on your finances, your time, and your peace of mind. We’ve helped countless pediatric practices spot hidden inefficiencies, fix the cracks in their processes, and finally feel confident in their revenue cycle.

Stop Losing Revenue: Fix These Pediatric Billing Mistakes

Every dollar matters when you’re caring for kids—and yet, billing mistakes often go unnoticed until they show up in your bottom line. Simple errors like a missed charge or an incorrect modifier can add up quickly. Some studies show nearly 20% of all claims are denied, and up to 60% of those are never resubmitted. That’s a lot of lost income your practice has already earned.

Here’s how to prevent common mistakes and keep more of what you’ve worked for:

• Missed Services: It’s easy to skip charges when the day is packed. Consider a daily checklist to catch missed charges before claims go out.
  Coding Errors: Pediatric-specific coding is complex. Keep a cheat sheet handy and train your team regularly.
• Eligibility Gaps: Insurance changes fast, especially for families. Verify eligibility at every visit to avoid denials.
• Filing Delays: Use reminders to catch claims before payer deadlines pass. Altus uses a 30-point checklist to track this precisely.
• Ignored Denials: Don’t leave money on the table. We never write off a claim without a fight—and you shouldn’t either.

Fixing these common issues can unlock significant revenue. Even a few changes can lead to tens of thousands in recovered income each year.

Essential Billing Metrics Every Pediatric Practice Needs

You can’t fix what you don’t measure—and that’s especially true in billing. Many pediatric practices check the bank account and monthly revenue totals, but that’s just scratching the surface. To really understand your financial health, you need to dig into the right metrics. When you do, you’ll see exactly where your billing is thriving and where attention is needed.

Here are the metrics we recommend monitoring consistently:

• Days in A/R: How long it takes to get paid. Faster payments mean stronger cash flow. Aim for under 30 days.
• A/R Over 90 Days: If too much of your receivables are aging, it’s a sign that claims or patient balances are being missed. Keep this under 15% of your total A/R.
• Claim Denial Rate: A high rate here means more rework, less revenue, and more staff stress. Target under 5%.
• Net Collection Rate: This is a big-picture view of how well you’re capturing the revenue you should. High-performing practices hit 95–99%. If you’re at 85%, there’s room to grow.
• Average Reimbursement Per Visit: Helps track if coding or payer mix shifts are affecting your revenue.
• Patient Collection Rate: You should aim to collect 90%+ of balances. Most successful practices collect at the time of service.

At Altus, we provide these metrics in your monthly reports, so you always know where you stand and where to focus next.

How Billing Errors Hurt Your Practice & How to Prevent Them

Nobody wants to admit it, but billing errors happen, and they can quietly cause big problems for your practice. Whether it’s a wrong code, a missed modifier, or a patient’s insurance that wasn’t updated, these mistakes often slip through the cracks. Over time, they chip away at your revenue and your team’s morale. But here’s the good news: most billing errors are fixable—and preventable.

How Billing Errors Hurt Your Practice

• Lost or Delayed Revenue: A missing modifier or incorrect CPT code can mean a claim is denied or underpaid. Sometimes the issue isn’t caught at all, and the money is never collected.
• Higher Operational Costs: Fixing errors takes time. Reworking claims, calling payers, resubmitting paperwork—it all adds up.
  Staff Burnout: Constant billing issues create a reactive, stressful environment. Over time, that can wear down even the best teams.
• Frustrated Patients: Billing mistakes often lead to confusing or inaccurate bills. Repeated mistakes can hurt trust and retention.
  Compliance Risks: Honest errors can still raise red flags with payers. Clean billing protects your reputation and reduces risk.

Best Practices to Prevent Billing Errors and Improve Accuracy

Given these consequences, error prevention should be a top priority. Here are strategies to minimize billing errors in your pediatric practice:

1. Add Checks and Balances: Don’t rely on one person to handle everything. Use tools to flag errors before submission.
2. Use Smart Technology: Modern billing tools catch age-specific codes, missing modifiers, and payer-specific rules.
3. Invest in Training: Coding rules change. Share updates regularly.
4. Standardize Documentation: If it’s not in the chart, it won’t make it onto the claim.
5. Consider Outside Help: Pediatric billing partners like Altus can apply best practices that prevent future problems.
6. Track Errors Over Time: Identify patterns and training opportunities.
   Create a No-Blame Culture: Encourage open communication. Teams fix more mistakes when they work together.

By dramatically reducing billing errors, your practice will see faster payments, fewer denials, and lower stress overall. It may take some effort to revamp processes and train staff, but it pays off. Imagine having confidence that each claim going out the door is 98% likely to get paid without a hiccup – that’s achievable and many practices do reach that level of performance (98% clean claims). Plus, a reputation for accurate billing and clear communication becomes a selling point to patients and a relief to your administrative team.

Denied Claims? How to Fix and Prevent Pediatric Denials

Even with a solid billing process, claim denials are part of life in pediatrics. But here’s the key: practices that consistently follow up, fix, and prevent denials don’t just get paid more—they get paid faster and with less stress.

At Altus, we believe in a zero-write-off mindset. That means every claim deserves a second look. Most denials are fixable, and many are preventable. Here’s how to handle them well and reduce how often they happen.

• Missing Prior Authorization: Often required for things like ADHD testing or certain therapies.
• Incomplete Insurance Info: Especially common with new babies or families with dual coverage.
• Service Not Covered: Some payers limit well visits or deny vaccines if billed incorrectly.
• Medical Necessity Denials: Rare for general pediatrics, but possible for specific treatments.
• Modifier/Coding Mistakes: Like forgetting the -25 when billing a sick visit with a well check.
• Coordination of Benefits Issues: Happens when two plans are covering the child and aren’t correctly prioritized.

Start by tracking which of these show up most in your denials. That data will guide your fixes.

 

How to Fix Denied Claims (Effective Denial Management):

1. Act Quickly: Don’t let EOBs pile up. Denials should be reviewed and addressed within days—not weeks.
2. Find the Cause: Review the denial code. Use payer portals or call if it’s unclear.
3. Resubmit or Appeal: Correct the claim if it’s a fixable issue. If it needs an appeal, include all documentation and submit within the timeframe.
4. Track the Follow-Up: Don’t just send it and hope. Mark your calendar to check in. Call if needed.
   Loop in the Patient (If Needed): If the family may owe a balance, explain early and clearly. It preserves trust and avoids surprise bills.

Persistence matters. Studies show more than half of denied claims that are appealed get paid—if someone follows through.

How to Prevent Pediatric Denials

• Verify Insurance at Every Visit: Even long-time patients may have new plans or updates.
• Get Prior Auths in Advance: Train your scheduling team to flag services that need them.
• Submit Clean Claims: Use tools to check for errors before submission. Altus runs every claim through a pediatric-specific checklist.
• Watch for Payer Updates: Insurance rules change often. Stay informed.
  Monitor Recurring Issues: If the same denials keep happening, it’s time for a process update.
• Make Denial Rate a Shared Metric: Set goals as a team and celebrate progress.

Denials are frustrating—but manageable. With clear processes and consistent follow-up, you can turn denied claims into paid ones, and cut down on how often they happen in the first place.

 

How Better Billing Can Help Your Front Desk Run Smoother

Billing may seem like a back-office task—but it begins and ends at the front desk. Your front-desk team is the first and last point of contact for every family, and when billing is clunky or unclear, they feel the pressure. But when it’s streamlined? The entire practice runs more smoothly.

Here’s how better billing processes can take the stress off your front desk—and create a better experience for everyone.

Clear Copay and Balance Collection at Check-In

Ever had a front-desk team member say, “I’m not sure what to collect today”? That uncertainty makes collections awkward and inconsistent. With a well-integrated billing system, your team can see in real time:

• Today’s copay
• Any past-due balances
• What to collect before the patient is seen

This clarity improves your collection rate and gives staff the confidence to communicate clearly with families.

Fewer Patient Calls and Billing Disputes

Clean, accurate claims mean fewer billing-related calls later. That saves your team time and reduces frustration. And when families do call, solid documentation helps your staff respond quickly and accurately.

At Altus, we document every step—from denial follow-ups to patient communications—so your team always knows what’s going on with each account.

Smoother Patient Flow at Check-In and Check-Out

When eligibility is checked in advance and billing notes are easy to access, visits move more quickly. Your team doesn’t have to scramble to figure out if a vaccine is covered or chase down billing codes.

Stronger Coordination Between Teams

Billing and front-desk teams should work together—not in silos. Better communication tools and regular check-ins help both teams stay aligned. At Altus, we support this with coaching that connects your billing and front-desk workflows.

Happier Patients

Families appreciate transparency. It builds trust when a receptionist can confidently say, “Your insurance has a $30 copay today, and there’s also a $15 balance from your last visit.”

That’s a better experience than a surprise bill weeks later—and it makes your practice feel organized and reliable.

Less Stress for Your Front Desk

Phones ringing, forms to file, walk-ins to manage—and on top of that, billing questions? When billing systems are inefficient, the front desk carries the burden. By simplifying billing, automating statements, and giving staff better tools, you create a calmer, more productive environment.

Empowered Financial Conversations

Your front desk often handles payment discussions. They need tools and training to do that well. A good billing partner supports this with:

• Scripts for common scenarios
• Easy ways to set up payment plans
• Access to billing history so nothing’s a mystery

At Altus, we help front-desk teams feel confident and supported in these conversations.

 

Is Your Fee Schedule Costing You Money? How to Find Out

Your fee schedule might not be something you think about often, but if it hasn’t been updated recently, it could be quietly costing your practice thousands each year. In pediatrics, where margins can be tight, getting paid fairly for every service matters.

Here’s why your fee schedule matters more than you might think—and how to make sure it’s working for you, not against you.

Why Fee Schedules Matter

Every service you provide has a price. That price—the one you set—is compared to what insurers are willing to pay. But here’s the catch: insurers won’t pay more than what you bill. So, if your fee is lower than what they allow, you’re leaving money on the table.

Let’s say a payer would allow $120 for a visit, but your fee is only $100. They’ll pay $100—and you’ve lost $20 without realizing it. This happens more often than many practices realize.

Signs You Might Be Undercharging

• You often receive payments where the paid amount equals your full charge (with no contractual write-off).
• You haven’t reviewed or updated your fees in over a year.
• Some services have random or inconsistent pricing.
• You’ve added new services (like telehealth or behavioral health visits) without adjusting your pricing strategy.
• You never see insurance adjustments (another sign your charges are too low).

How to Review Your Fee Schedule

Start by comparing your most-used CPT codes against what major payers allow. Look at:

• Your current charge
• Medicare/Medicaid rates
• Commercial payer allowable amounts

For pediatric practices, experts often recommend setting fees at 200-250% of Medicare rates. This helps ensure you’re above all payer allowances and not undercharging for your services.

At Altus, we recommend regular reviews of your contracts to ensure that those willing to pay even more than 250% of Medicare receive a charge high enough to get that payment.

What About Vaccines?

Vaccines are a special case in pediatrics. Make sure:

• Your vaccine fees at least cover your cost.
• Your administration fees are in line with what insurers allow, and not below.
• You’re tracking what’s billed to VFC vs private insurance to avoid loss.

Adjust Fees Thoughtfully

You don’t have to overhaul everything at once. Start with your most common services. Adjust your fees to better reflect your value and stay ahead of rising costs. For most insured patients, a fee increase won’t affect what they pay, but it could significantly impact what you collect from payers.

Transparency matters too. If you’re raising self-pay rates, communicate clearly with families so there are no surprises.

At Altus, we perform regular fee schedule reviews for our clients. It’s one of the simplest ways to increase revenue, without adding more patients or working more hours.

Thrive with Proactive Billing and Expert Support

Pediatricians pour their energy into caring for children, and your billing process should support that mission, not work against it. A well-run revenue cycle doesn’t just help your practice get paid. It gives your team time back, reduces stress, and makes your entire operation stronger.

We’ve covered a lot in this guide:

• How to stop losing revenue to common billing mistakes
• Which metrics help you stay on track
• How to fix and prevent denials
• Ways to make billing easier on your front desk
• And how to make sure your fee schedule isn’t holding you back

These aren’t just financial strategies—they’re quality-of-life upgrades for your whole team.

Take Control with Proactive Processes

The same way you approach pediatric care with prevention in mind, your billing should follow suit. Small steps like reviewing your KPIs monthly or running a fee audit once a year can prevent big problems down the road.

And the sooner you start, the more control you gain.

You Don’t Have to Do It Alone

If billing is something that feels overwhelming or out of sync, it doesn’t have to stay that way. Many practices hit a point where they’ve outgrown their systems or need more specialized support.

That’s where we come in.

At Altus, we work exclusively with pediatric practices. Our billing experts understand your unique codes, your patients, and your payers. We bring a pediatric-specific lens to everything we do—so you can stop patching problems and start making real progress.

Ready for a Better Way to Bill?

If your A/R is creeping up, if denials are eating into your revenue, or if your billing team is constantly chasing their tails, it might be time for a change. Trust your instincts. You know when something isn’t working.

Altus was built to be the partner we wished existed when we were in your shoes: responsive, pediatric-specific, and committed to helping you thrive.

Take the First Step

You don’t have to overhaul everything tomorrow. Start with these simple actions:

• Identify 2–3 focus areas from this guide that you’d like to improve
• Host a quick team meeting to talk about what’s working and what’s not
• Track one new KPI—just start measuring
• Or, if you’re ready, reach out for a free consultation

We’ll take a look at your current billing performance and help you identify quick wins and long-term improvements.

At Altus, our mission is simple: Make sure nothing slips through the cracks and every service gets paid for. That way, you can focus on what really matters—caring for kids.

Your practice deserves to thrive. Let us help you get there.