By: Paul Mason, Director of Strategic Partnerships at LTCPro
For: administrators and business office managers at Skilled Nursing Facilities (SNFs) and Assisted Living Facilities (ALFs) across the United States trying to decide whether AR needs a dedicated specialist or just more hours from the people already handling it.
Key Takeaway: Roughly 57 percent of denied Medicare Advantage claims get overturned when appealed, yet industry data shows a large share of denied claims, sometimes more than half, never get resubmitted at all. That gap comes down to bandwidth and judgment, not technology, and closing it is exactly what a dedicated Receivable Solutions Specialist exists to do.
In This Article
- What a Receivable Solutions Specialist Actually Is
- Five Decisions Only a Dedicated Specialist Has Time to Make Well
- What Happens Without One
- How LTCPro’s Specialists Work
- Frequently Asked Questions
In Medicare Advantage specifically, 57 percent of initial claim denials get overturned once a facility actually appeals them, according to research published in Health Affairs. And yet the same body of industry data shows that somewhere between 35 and 60 percent of denied claims are never resubmitted at all, according to AHIMA Journal research on claims denial resolution. Read those two numbers together and the story isn’t that appeals don’t work. It’s that most organizations, across SNFs and ALFs nationwide in the United States, don’t have anyone with the time to file them.
That gap is where a Receivable Solutions Specialist earns their keep. Not by working harder at the same generalized billing tasks everyone else on a business office team is already stretched across, but by owning AR as a full-time discipline with the judgment to know which claims are worth fighting for and the bandwidth to actually fight for them.
What a Receivable Solutions Specialist Actually Is
Most SNFs and ALFs don’t lack someone touching accounts receivable. They lack someone whose entire job is accounts receivable. A bookkeeper, a billing coordinator, or an office manager wearing five hats can process a submitted claim and post a payment when it arrives.
What that person usually can’t do, because nothing in their day allows for it, is track every claim’s status against its appeal deadline, notice the pattern behind three denials from the same payer in a month, or sit down with an anxious family member and turn a confusing balance into a manageable payment plan.
A Receivable Solutions Specialist is built around exactly that gap. The role sits at the intersection of eligibility verification, claims tracking, denial strategy, family communication, and payment reconciliation, not as five separate tasks assigned to whoever has a spare hour, but as one connected discipline where catching a problem at eligibility prevents a denial three weeks later, and knowing a family’s situation changes how a balance conversation gets handled.
Five Decisions Only a Dedicated Specialist Has Time to Make Well
The value of the role isn’t really in the tasks. Generalists can process claims and post payments too. The value is in the judgment calls that only get made well when someone has the time and the accumulated pattern-recognition to make them.
Deciding whether a claim is worth appealing, and how hard, is the first and most consequential one. With appeal overturn rates around 57 percent for Medicare Advantage denials but rework cost running anywhere from $25 to $181 per claim, the math on any given denial isn’t obvious at a glance.
A specialist who tracks denial patterns by payer and by reason code can tell the difference between a claim worth a documentation-heavy appeal and one that’s a faster win through a simple resubmission, a distinction a generalist triaging claims between other tasks usually doesn’t have the pattern history to make quickly.
Catching an eligibility shift before it becomes a denial is the second. A resident moving from Medicare Part A toward Medicare Advantage, or drifting toward Medicaid spend-down mid-stay, changes the billing rules in ways that don’t announce themselves.
A specialist watching for these transitions catches them before a claim goes out under the wrong payer, rather than after, when the fix costs far more than the original mistake would have.
Knowing when a family conversation needs a phone call instead of another statement is the third, and it’s the one furthest from anything a system alone can decide. A balance that’s gone unpaid for 90 days might mean the family is avoiding it, or it might mean they’re mid-way through a Medicaid application and genuinely don’t know what they still owe. A specialist who’s actually spoken with the family knows which. A templated reminder doesn’t.
Spotting a reconciliation mismatch before month-end closes it out is the fourth. An ERA payment that doesn’t match the expected reimbursement, a remittance that’s short by an amount too small to trigger an automatic flag, these are the errors that quietly become permanent once a books closes around them. Catching them requires someone reviewing reconciliation with enough regularity and enough context to notice a number that looks slightly off.
And knowing when to escalate a denial pattern to leadership, rather than just working around it claim by claim, is the fifth. Three denials from the same payer for the same reason in a month signal something upstream, a documentation gap, a coding pattern, an authorization process, that needs to change, not three unrelated problems to work around individually. A specialist tracking denials closely enough to notice the pattern is the one who can flag it before it costs a facility the tenth denial, not just the third.
None of these five decisions show up on a job description as “responsibilities.” They show up as the difference between a facility that recovers what it’s owed and one that quietly writes off more of it than it realizes.
Facilities weighing whether this role justifies a dedicated hire, or a dedicated outsourced specialist, are usually better served comparing it against what currently gets missed rather than what currently gets done. LTCPro’s Receivable Solutions Specialists are built around exactly this judgment layer, not just claims processing.
What Happens Without One
The cost of not having dedicated AR judgment doesn’t show up as a single number on a report. It shows up distributed across a dozen smaller ones that are easy to miss individually.
Administrative cost per denied claim rose from $43.84 in 2022 to $57.23 in 2023 industry-wide, according to Premier Inc. research, and that’s before counting the claims that never get reworked at all. Revenue cycle staffing itself is under real pressure too: turnover in RCM roles runs an estimated 11 to 40 percent, which means the person who built up the payer-specific pattern recognition a facility depends on is statistically likely to be gone within a year or two, taking that judgment with them unless it’s been built into a role and a process rather than one person’s memory.
Multiply the unappealed-denial gap across a facility’s full claim volume and the number gets harder to ignore. A facility that lets even a third of its denials go unappealed, when well over half of Medicare Advantage denials succeed on appeal, is leaving a predictable, recoverable share of its own revenue on the table every single month, not because the care wasn’t billable, but because nobody had the bandwidth to make the case for it.
See what your facility’s own denial and appeal pattern actually looks like. Find out which denials are worth appealing and which are quietly going unresubmitted.
Request an AR Pattern Review →How LTCPro’s Specialists Work
LTCPro’s Receivable Solutions Specialists are trained specifically in long-term care finance, not general medical billing, which matters because the judgment calls above depend on payer-specific and long-term-care-specific pattern recognition that a generalist billing background doesn’t build.
Specialists combine automation, ERA posting, 837 claim submissions, real-time tracking dashboards, with the human judgment that decides which denial gets a documentation-heavy appeal and which family balance needs a phone call instead of a third statement.
The model is built to scale the same way whether a facility is a single site working with one specialist or a multi-state operator with a specialist team, since the judgment layer doesn’t change with facility count, only the volume it’s applied to.
Not sure whether this fits your facility? Talk to LTCPro about adding a dedicated AR specialist and walk through your current AR coverage against the gap generalist coverage tends to leave open.
Talk to LTCPro About AR Support →Real, client-specific results, denial rates recovered, AR days improved, working capital unlocked, are worth asking for directly once a facility is evaluating a specific engagement, rather than relying on an industry-wide estimate to stand in for what a specific specialist relationship would deliver.
Frequently Asked Questions
How is a Receivable Solutions Specialist different from a regular billing coordinator?
A billing coordinator typically processes claims and posts payments as part of a broader set of office duties. A Receivable Solutions Specialist owns the full AR lifecycle as a dedicated discipline, tracking, denial strategy, family communication, and reconciliation, with the time and pattern recognition to make judgment calls a generalist role usually doesn’t have room for.
Is it worth appealing every denied claim?
Not necessarily, since rework costs money regardless of outcome, but the data suggests most facilities err too far toward not appealing rather than too far toward over-appealing. With Medicare Advantage appeal overturn rates around 57 percent, a facility that isn’t appealing recoverable denials is very likely leaving real revenue behind.
Can a small, single-site facility justify a dedicated AR specialist?
Yes, and often more so than a larger facility. A single-site facility usually has fewer staff hours to cover the same AR complexity, which means the judgment gap a dedicated specialist closes is proportionally larger relative to the facility’s total administrative capacity.
Does the Receivable Solutions Specialist model work the same way for operators with facilities in multiple states?
Yes, though the underlying complexity grows with each state added. Medicare Advantage rules and appeal processes stay federally consistent, but Medicaid eligibility, spend-down rules, and payer-specific documentation standards vary by state, which means a specialist supporting a multi-state operator needs state-by-state pattern recognition on top of the payer-specific judgment described above. LTCPro’s specialist model scales the same way whether it’s one specialist covering a single facility or a specialist team covering an operator’s full multi-state footprint in the U.S.
LTCPro provides dedicated Receivable Solutions Specialists and accounts receivable support built specifically for skilled nursing and assisted living facilities across the United States.
Ready to see this applied to your own numbers? Request a consultation built around your facility’s actual claim and denial history.
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