Two months into our review of an independent pain management practice, the lead practitioner admitted, “We bill for every procedure we perform. Still, cash keeps slipping.”
A routine diagnostic showed multiple small issues: missed modifiers on bilateral injections, gaps in prior authorization workflows, and inconsistent patient collections.
Together, those gaps added up to an avoidable 8% of annual revenue, money that could have covered a top clinician’s salary.
That cumulative effect is why benchmarking your pain management practice isn’t an HR exercise. It’s a revenue imperative.
What is benchmarking for a pain management practice, and why should you care?
Benchmarking is a structured way to measure your practice against peer performance and best practices across the revenue cycle.
For pain practices, this typically includes five practical categories: Eligibility & Authorizations; Coding & Charge Capture; Denials & A/R Follow-Up; Patient Collections; and Billing Analytics & Metrics.
These categories together form a framework that highlights where processes perform well and where revenue might be silently leaking.
What are the top leak points in a pain practice?
Across the specialty, certain revenue gaps show up repeatedly: missed modifiers (e.g., -50, -59, LT/RT), authorisation failures (especially for SCS trials, RFA, or SI joint injections), inaccurate coding, weak point-of-service collections, and lack of analytics.
Each by itself may look small; together they compound into meaningful lost revenue.
How should you measure performance, which Key Performance Indicators (KPIs) matter?
Do a follow-up monthly for:
- Claim denial rate: Industry guidance suggests keeping this low; HFMA (Healthcare Financial Management Association) often cites ~5% or less as a useful target for many organizations.
- Days in A/R: Aim for under 40 days; many best-practice guides place a 30–40 day window as a benchmark.
- Auth denial rate: Below 2% is an attainable target for well-managed practices.
- Patient collections at time of service: At least 80% of patient balances collected before procedures is considered healthy.
- Denial resolution time: Aim to work on denials within 3–5 days of receipt.
Tracking these KPIs consistently turns performance review into a data-driven conversation rather than a reactive scramble.
Where do practices actually lose 5–15% of revenue?
Independent studies and audits across healthcare revenue cycle management consistently show that most practices lose between 5 to15% of annual revenue due to denials, underbilling, or process inefficiencies.
- Broader studies of revenue cycle inefficiencies show providers can fail to collect 2–5% of net patient revenue due to RCM inefficiencies.
- Industry benchmarks for denial rates vary by payer and specialty. HFMA recommends keeping denial rates around 5% or less, but many specialty practices end up with higher rates when workflows aren’t fully optimized.
- Prior authorization denial rates remain a major challenge. According to an analysis by the Kaiser Family Foundation (KFF), Medicare Advantage plans denied about 6.4% of prior authorization requests in 2023. The denial rate isn’t the same across the board — it varies depending on the plan and the type of service requested.
The American Medical Association (AMA) has also reported that the effort required to manage prior authorizations has been rising every year, adding more administrative pressure on practices.
Across pain management, even well-run practices can leave substantial revenue on the table — not from lack of effort, but from small, systemic misses that go unnoticed without structured benchmarking.
What an Optimized Workflow Looks Like: A Practical Checklist
A well-structured revenue workflow helps independent pain practices reduce preventable denials, improve cash flow, and keep day-to-day operations running smoothly. Here’s a quick, practical checklist you can use to evaluate where your own processes stand:
- Verify Eligibility Twice
Confirm coverage at scheduling and again before the procedure. Clearly document who owns each step so nothing slips through the cracks.
- Strengthen Authorization Workflows
Maintain a centralized log for all prior authorizations and set a target of keeping your authorization-related denials below 2%.
- Standardize Clinical & Coding Templates
Make sure documentation supports laterality, bilateral and multi-level coding, and ensure your team is trained specifically in interventional pain coding.
- Address Denials Promptly
Triage denials by type — authorization, coding, or documentation — and aim to resolve them within 3–5 days. Track root causes to prevent repeats.
- Collect at the Point of Service
Strive to collect at least 80% of patient responsibility before the procedure, while offering flexible payment options when appropriate.
- Use Analytics Consistently
Monitor your denial rate, clean claim rate, net collections, and days in A/R each month, and conduct an annual benchmark against peer practices.
Want to assess how your own practice measures up?
Download the PainMed-PA Billing Diagnostic to guide your assessment.
How can AI and Mainer.Ai speed up recovery and tighten controls?
Mainer.Ai is an AI-powered billing intelligence platform built specifically for pain management practices.
MAINER.AI is the world’s first pain management-focused AI model developed by PainmedPA. Implementing the six steps above would help — but that still leaves the human problem: scale and attention. That’s where www.mainer.ai matters.
Unlike generic tools, it understands the unique workflows, procedures, and coding patterns common in interventional pain, and helps practices catch revenue-impacting issues before they turn into denials or delays.
- Automated eligibility & auth detection flags missing or expiring authorizations before the date of service (reduces preventable auth denials).
- AI-assisted coding validation suggests correct modifiers and multi-level codes and surfaces likely underbilled procedures for audit.
- Denial pattern detection groups denials by root cause and predicts which claims need executive attention to keep days in A/R low.
- Real-time dashboards & benchmarking compares your KPIs to peer practice benchmarks and highlights the highest ROI fixes.
A Simple Monthly Rhythm to Keep Your Practice Financially Healthy
Independent pain practitioners don’t need lengthy meetings or complicated performance reviews. What they need is a simple, steady routine that keeps revenue predictable and prevents small issues from becoming expensive leaks.
A quick monthly rhythm supported by real-time insights from Mainer.Ai’s dashboard is often all it takes.
Here’s how to make it work:
1️⃣ Start with a quick glance at your real-time financial snapshot
Instead of pulling reports or digging through claims, open your Mainer.Ai dashboard and check the essentials:
- Denial trends
- Days in A/R
- Upcoming or missing authorizations
- Any underbilled or incorrectly coded procedures
- Payers showing slower payment behavior
A 30-second glance gives you a clear sense of what’s healthy and what’s drifting.
2️⃣ Spot the one issue that matters most this month
With all your patterns surfaced automatically, you don’t have to sift through data.
Just identify the single issue that had the biggest impact, for example:
- An uptick in medical necessity denials
- A payer-specific slowdown
- Recurring missing modifiers
- Delays caused by expired prior authorizations
Focusing on one issue keeps the process realistic for smaller teams.
3️⃣ Make one simple operational adjustment
Independent practices get the biggest ROI from tiny but targeted changes, such as:
- Updating a documentation template
- Adding a quick eligibility check at scheduling
- Ensuring expiring authorizations are flagged earlier
- Using AI-assisted coding suggestions for certain procedures
These changes take minutes but prevent ongoing revenue leakage.
4️⃣ Review the dashboard to see what has improved since your last check-in
No spreadsheets, no reports.
Your Mainer.Ai dashboard will automatically show you:
- What improved
- What didn’t
- Whether the issue you addressed actually moved the needle
- What new patterns have emerged
This turns your monthly review into a simple yes/no progress check — instead of a deep-dive analysis.
5️⃣ Let AI do the heavy lifting all month
Between these monthly touchpoints, Mainer.Ai continuously surfaces:
- new denial patterns
- shifts in payer behavior
- underpayments
- coding discrepancies
- high-risk claims that need attention
So, when you sit down for your next check-in, the platform has already done the thinking for you.
In short, You don’t need a complex benchmarking meeting to stay financially healthy.
A short monthly check-in — powered by real-time AI insights — gives independent practitioners clarity, control, and consistent revenue growth without adding work to already full schedules.
FAQ
Q: How much revenue should a pain practice expect to lose if it has no formal benchmarking?
Most pain practices lose between 5–15% of annual revenue to denials, underbilling, and workflow gaps — figures supported by multiple industry audits and RCM analyses.
Q: What’s an acceptable denial rate?
While targets vary by specialty and payer mix, HFMA guidance suggests aiming for ~5% or less in many contexts — but specialty practices should set internal targets based on their historic performance and continuously improve.
Q: How fast should denials be worked?
Best-performing practices work denials within 3–5 days of receipt and track denials by type to address root causes.
Q: Are prior authorizations really that big a problem?
Yes. KFF and AMA reporting show material denial rates for prior authorizations (KFF reported ~6.4% fully/partially denied in 2023 for MA requests) and a heavy administrative burden — making auth process optimization high ROI for many practices.
Q: Can technology really find missed modifiers and underbilling?
Modern coding-audit tools and AI-assisted workflows have documented success in surfacing likely underbilled services and modifier mistakes; incorporating quarterly audits plus automation reduces both denials and underpayment.
Q: Will Mainer.Ai replace my billing team or billing company?
No. Mainer.Ai will not replace your staff or billing partner — it will augment them.
The platform acts like a second set of eyes, catching underpayments, denials, coding issues, and missing authorizations that humans often miss because of time constraints.
Your team still submits and manages claims, but Mainer.Ai ensures they’re working on the right things first and prevents costly oversights.
Q: Is Mainer.Ai difficult to implement for a small, independent practice?
Not at all. Most independent practices are fully onboarded within a few days.
There’s no disruption to your workflow, no change in your EHR or billing software, and no technical setup required from your side.
Once connected, the dashboard automatically begins surfacing insights, denial patterns, and revenue opportunities — without adding extra work for you or your staff.
Mainer.Ai was built specifically for pain management workflows — combining specialty billing expertise with AI to reduce denials, improve coding accuracy, automate revenue-cycle intelligence, and maximize revenue from each procedure.
Schedule a free billing review with our team to get a customized diagnostic and remediation plan that shows targeted revenue opportunities. Call us today on (512) 868-1762. Visit our website at www.pmpa.com