The Things Your ERAs Have Been Trying to Tell You

If you run a small or mid-sized ambulatory practice, work with ERAs, or know your way around an 835 file — this one’s for you.

The 1980s-era X12 protocol may not sound glamorous, but it quietly holds more operational truth about your revenue cycle than most modern dashboards. It’s time we listen to what it’s been trying to tell us.

When I started this RCM sabbatical, I had a simple goal: to understand coding the way coders do.

So, I bought the AAPC CPT 2025 book, neatly tabbed every section (because information organization genuinely gives me joy 😅), and started preparing for the CPC certification — just to see what coding teaches you about the clinical and financial world.

Then I attended my first local AAPC chapter meeting.

I sat next to a kind woman who quickly became my partner in curiosity. Halfway through the session, she turned to me and said:

“You don’t need to memorize the whole book — you just need to know how to look up a code.”

That single line stopped me.

It was my aha moment.

Because I realized — the behavioral health practice I was helping didn’t need to know the entire CPT universe either. They were billing maybe 20 codes total.

And like most practices, those 20 CPTs represented almost all their revenue. The Pareto principle in action, hiding in plain sight.

That small conversation changed my entire approach. I didn’t need to conquer the complexity. I needed to go deep on the few codes that actually mattered.

And that’s where my focus on ERAs began — where the real story of denials, underpayments, and workflow leaks quietly lives.

A Stubborn Hunch

When I stepped into my sabbatical, I had one stubborn belief:

If you stare at ERAs long enough, they’ll quietly tell you everything that’s broken in your revenue cycle.

Not in a mystical way. In a very boring, very precise way.

When X12 gave us the 835 with CARC/RARC codes, the intent was clear: every denial should say why it happened — eligibility, prior auth, bundling, modifier, credentialing, duplicate. The plumbing is all there.

But in real life, most practices are drowning.

You’re seeing patients, hiring, covering no-shows, closing charts, filing claims, answering portals, juggling payers, expanding services. Sitting down for three hours and reading ERAs “for patterns” is a luxury you don’t have.

So the data piles up. The same preventable denials repeat. AR days creep. Underpayments slide through because at least something got paid. And everyone calls it normal.

I don’t buy that.

A Practice That Let the Data Talk

A behavioral-health group recently gave me their July–November ERAs and said, essentially:

“We know there’s signal in here. We don’t have the time. Will you look?”

I am so grateful to Dr. B — he asked. It was so much fun finding the needle in the ERA hay!

So we did the work.

1. Pulled all ERAs for July–Nov.

2. Focused on their top CPTs.

3. Overlaid Medicare fee schedules by MAC.

4. Looked at NPIs by provider type (who should be paid 100% vs 75%).

5. Compared each payer’s behavior against those benchmarks.

6. Broke out preventable denial categories and provider-level patterns.

What surfaced:

• Eligibility denials: ~$31,000 in four months. Coverage inactive, not checked before visit.

• Prior Authorization: ~11K in four months. Prior Authorization needed for certain CPTs.

• Underpayments: certain payers paying ~0.76× Medicare while others paid 1.0–1.4× for identical codes.

• Provider coaching: same clinicians repeatedly triggering the same denial reasons, while peers had none.

These numbers are from one anonymized behavioral health group over four months, but the patterns are not unique.

The hunch held: every denial really is a teacher — if you let it be.

The Boring Categories that Quietly Eat Your Revenue

Once you organize ERAs, the preventable buckets are painfully familiar:

• Eligibility not verified or updated

• Prior auth missing or expired

• Duplicate submissions

• Credentialing / enrollment misalignment

• Basic modifier or bundling logic missed

These aren’t complex payer traps. They’re everyday workflow challenges hiding in plain sight.

It is also prudent not to obsess over the transaction fees your EHR platform charges for real-time eligibility. A simple habit like checking eligibility before the appointment will save you the heartache of discovering inactive coverage only after the visit — and only after the denial. That’s too long a revenue cycle.

Spend the 10-cent transaction fee to prevent hundreds of dollars in lost revenue and rework.

The same applies to Prior Authorization. Get the list of CPT codes from each payer that require prior auth and post it right where scheduling and front-desk staff can see it. Get it done before the patient shows up.

Just these two alone — pre-visit eligibility and pre-visit prior auth — can dramatically reduce surprise bills for patients and support a healthier, more predictable cash flow for your practice.

I’m glad this group had the courage to ask their ERAs the right questions — now they have proof of which workflow tweaks matter and how to prioritize them by dollar impact.

The goal isn’t overnight transformation.

It’s awareness in Week 1, followed by slow, steady improvement — creating simple SOPs, re-checking ERAs, and asking:

“Did our preventable denials go down?”

That quiet, continuous reflection — that kaizen mindset — is what leads to meaningful reduction in preventable denials.

No one can promise zero denials. But not pausing to even look at preventable ones? That’s leaking money left and right — and burning your timely filing window while you do it.

And yes, the human side matters: a patient should not discover their plan is inactive via a surprise bill 30 days after an honest therapy session.

We do not need therapy for a shocking bill.

Underpayments: The Non-Denial Denial

If a claim pays $62 instead of $83, no one calls it a denial. It posts. Everyone moves on.

But if Medicare in your MAC pays $100 for a code, and:

• One commercial payer consistently pays $140,

• Another sits quietly at $76,

for the same code, same contract type, same market — that gap is not random.

When you:

• Anchor to the right Medicare rate for your MAC,

• Apply 75% vs 100% correctly (e.g., therapist vs clinical psychologist),

• Line up allowed amounts by payer, CPT, modifier, and provider type,

you start to see systematic underpayment patterns, not one-off noise.

That is not “the cost of doing business.” That’s an opportunity to renegotiate — with evidence, not guesswork.

Your Own People Are Part of the Answer

In this group, some therapists had consistently clean claims. Same codes. Same payers. Same tools. Different discipline.

Your ERAs already hold your internal benchmarks:

• Who rarely triggers preventable denials

• Who repeats the same avoidable errors

• Which habits map to clean claims

Find the quiet top performers. Document what they do right. Turn that into checklists, micro-training, and peer learning.

That’s how you move quality without more noise.

A Simple Way to Start

I can’t sit with every practice for weeks and dissect their ERAs — though I’d happily do it for a few if time allows.

But for anyone curious to take a first look, I put together a short Week 0 Revenue Cycle Health Check form:

👉https://forms.gle/Xsfprf1Ly6DcBHhs8

It’s simple:

• Share your top 5 CPT codes.

• I’ll map them to your MAC jurisdiction’s Medicare rates.

• I’ll add basic NCCI / policy hygiene observations.

You can use that to:

• Check if your current payments make sense.

• Spot obvious underpayment or edit risk.

• Decide if you want to go deeper — on your own or together.

No credit card. No campaign.

If you’d rather just DM me, I can spend a few weeks staring at your ERAs, optimize your workflows to reduce preventable denials, and arm you to the teeth for your next payer renegotiation.

If this sounds uncomfortably familiar when you think about your own ERAs, you’re exactly who I wrote this for.

The point isn’t to sell a tool. It’s to remind you that the data already sitting in your 835s is more valuable than most dashboards you’ll ever buy.

ERA isn’t an afterthought. It’s the mirror.

Look in it.

No AI needed — just basic statistics, mean, median, mode, and standard deviation will do. 😄