# Houston Family Medicine Case Study

> A 12 provider Houston family medicine group lifted collections 29% in six months. See the modifier 25, prior authorization and admin payroll math.

Source: https://webillhealth.com/case-studies/houston-family-medicine/  
Publisher: WeBill Health  
Last updated: October 27, 2026

Case study · Family Medicine · Houston, Texas

## 29% more collected in six months for a 12 provider Houston family medicine group

Two clinics, six providers each, billing commercial plans, Medicare and Texas Medicaid STAR. WeBill Health took over prior authorization, put payer rules in front of every claim and ran the revenue cycle end to end. Collections rose 21% by month three and 29% by month six.

12 providers2 clinics$4,324,800 collected the year beforeMeasured at months 3 and 6

**+$104,516**A month by month six, from $360,400 to $464,916

**+$75,684**A month by month three, a 21% lift

**4.6%**Of claim lines denied, down from 17.6%

**$307,662**Less admin payroll a year, 9 roles down to 4

Worked example. Built from Houston payer listings, Medicare and Texas rules, the AMA 2025 prior authorization survey and Houston wage data. Every result below ties back to the practice profile.

The practice

## A front desk doing payer work on top of full schedules

Each clinic runs six providers: three early career, two mid career and one senior. Preventive visits, chronic care and same day problems share one schedule, which is exactly where modifier 25 and prior authorization rules decide what gets paid.

| Providers | 12 across two Houston area clinics |
|---|---|
| Monthly collections per provider | Early career $23,850, mid career $33,125, senior $42,400 |
| Monthly collections | $360,400, or $180,200 per clinic |
| Visits a month | 3,400, an average of $106 collected per visit |
| Admin team | 9 people: front desk, authorization coordinators and one biller |

What the first month showed

### 598 of 3,400 claim lines denied

17.6% of everything billed came back unpaid, and half of the routine denials were written off without an appeal.

### 238 modifier 25 visits unpaid a month

Problem visits billed beside a physical, an injection or a minor procedure were bundled away because the note did not separate the two services.

### 76 provider hours a week on prior authorization

Two coordinators covered 80 hours. The providers carried the rest, about 6.3 hours each.

### 64% of patient balances collected

Deductibles and coinsurance were billed after the visit and many were never paid.

Payer mix

## Who pays this practice, and how much per visit

The visit mix and the amount collected per visit for each payer group produce the baseline exactly.

| Payer group | Visits a month | Share | Collected per visit | Monthly |
|---|---|---|---|---|
| Commercial | 1,360 | 40% | $125 | $170,000 |
| Medicare and Medicare Advantage | 850 | 25% | $118 | $100,300 |
| Texas Medicaid STAR | 850 | 25% | $70 | $59,500 |
| Self pay | 340 | 10% | $90 | $30,600 |
| Total | 3,400 | 100% | $106 | $360,400 |

### Medicare

Part B claims go to Novitas Solutions, the Medicare contractor for Texas (Jurisdiction H). Medicare Advantage volume runs through carriers active in Harris County such as Humana, UnitedHealthcare and Aetna, each with its own authorization list.

### Commercial

Blue Cross and Blue Shield of Texas, UnitedHealthcare, Aetna and Cigna. These are the plans where the Texas gold card law can remove prior authorization, and where contract variances hide underpayments.

### Texas Medicaid STAR, Harris service area

Community Health Choice, Molina, Texas Children’s Health Plan, UnitedHealthcare Community Plan and Wellpoint. Each plan runs its own authorization portal and its own modifier 25 edits.

Codes and conditions

## Where modifier 25 shows up in this schedule

Modifier 25 tells the payer a significant, separately identifiable problem visit happened on the same day as a preventive service or a procedure. The note has to show the separate work, or the E/M is bundled into the other service.

| Same day pairing | Codes | Typical conditions (ICD 10) |
|---|---|---|
| Physical plus a problem visit | `99381` to `99397` with `99212` to `99215` and modifier 25 | Hypertension `I10`, type 2 diabetes with hyperglycemia `E11.65`, hyperlipidemia `E78.5`, generalized anxiety `F41.1` |
| Medicare wellness visit plus a problem visit | `G0438` or `G0439` with an E/M, modifier 25, and `G2211` where the visit is part of ongoing care | Chronic conditions managed over time, such as `I10` and `E11.65` |
| Joint injection plus a visit | `20610`, 0 day global, with an E/M and modifier 25 only for separate work | Primary osteoarthritis, right knee `M17.11` |
| Wart destruction plus a visit | `17110`, 10 day global | Other viral warts `B07.8` |
| Cerumen removal plus a visit | `69210`, 0 day global | Impacted cerumen, right ear `H61.21` |
| Vaccines plus a sick visit | `90471` and `90472` with an E/M and modifier 25 | Acute upper respiratory infection `J06.9`, low back pain `M54.50` |

Since January 1, 2025, Medicare pays `G2211` on an E/M with modifier 25 when the same day service is a wellness visit, a vaccine administration or a Part B preventive service. CMS has also proposed paying only 50% of an E/M billed with modifier 25 beside a 0, 10 or 90 day global procedure starting in 2027. That rule is not final. [Read our breakdown of the proposal](https://webillhealth.com/modifier-25-family-medicine-ama-withdraw-cy2027/).

What WeBill Health changed

## Three jobs moved off the clinics’ desks

Every claim received human pre submission review against our payer rule libraries for each carrier this practice bills. When a payer changed a policy, an expert updated the library and applied it to the next claim.

Payer intelligence

### Know each payer’s rule before the claim goes out

* Modifier 25 documentation standard built into the visit note
* Edits for each Medicare, Medicare Advantage, commercial and STAR plan
* G2211 added where Medicare allows it
* Contracts loaded so every payment is checked against the agreed rate

Prior authorization

### Taken off the clinic’s desk entirely

* Every injection and in office procedure authorized before the visit
* Expiration dates tracked so no service lands on a lapsed approval
* Approval rates tracked against the Texas gold card threshold

Revenue cycle control

### One team from check in to the last dollar

* Eligibility and benefits verified before each appointment
* Patient estimates collected at check in
* Every denial worked to appeal or correction, none written off by default
* E/M level matched to the documented decision making or time

The math

## Where the 21% and the 29% came from

Eight changes, each counted in claims or visits and multiplied by what those claims pay. Gains are measured on new dates of service only. Old A/R recovered during the takeover is not included.

| Change | Month 3 | Month 6 |
|---|---|---|
| Modifier 25 visits paid238 of 680 same day problem visits went unpaid each month. That fell to 68 by month 3 and 34 by month 6. | $11,050 | $13,260 |
| Denials worked instead of written off340 other claims denied a month, 170 of them written off. Write offs fell to 68, then 34. | $10,812 | $14,416 |
| Authorized in office services paid20 of 80 in office injections and procedures a month were denied for a missing or expired authorization. That fell to 8, then 2. | $3,780 | $5,670 |
| Visits coded to the level the note supportsPre submission review moved 170 visits a month, then 272, from 99213 to a documented 99214. | $7,140 | $11,424 |
| G2211 added where it applies238 of 340 traditional Medicare visits a month are longitudinal primary care. None carried G2211 before. | $3,808 | $3,808 |
| Patient balances collected at the visitCopays, deductibles and coinsurance owed: $87,800 a month. Share collected rose from 64% to 81%, then 87%. | $14,926 | $20,194 |
| Underpaid commercial claims recovered136 commercial claims a month paid an average $29 under contract. Recovery began in month 4, once contracts were loaded. | $0 | $3,944 |
| Provider time returned to patientsWith prior authorization off their desks, each provider added 19 visits a month by month 3 and 25 by month 6. | $24,168 | $31,800 |
| Added collections a month | $75,684 | $104,516 |
| Monthly collections | $436,084 | $464,916 |
| Change against the $360,400 baseline | +21% | +29% |

Rates used: a separately paid problem visit collects $65 on average, a recovered denial collects the practice average of $106, an authorized injection or procedure $315, a move from 99213 to 99214 $42 more, and G2211 about $16. Added visits collect the practice average of $106.

Why the added visits are realistic: the AMA 2025 survey puts prior authorization at 13 hours a week per physician, or 156 hours for 12 providers. Coordinators covered 80, leaving 76 hours with the providers. 25 extra 20 minute visits a month use about 1.9 hours a week per provider, about 30% of the 6.3 hours each one got back.

What the front desk costs

## Admin payroll fell from $494,862 to $187,200 a year

Primary care practices run about 0.75 administrative staff per physician, which puts this group at 9 people. Eligibility checks, prior authorization and billing moved to WeBill Health. The front desk kept four people, two per clinic, for check in, check out and phones.

Before, admin payroll took 11.4% of collections. At month six it takes 3.4%.

Admin payroll before$494,862

Admin payroll at month six$187,200

Payroll removed each year$307,662

| Role | Before | After | Houston hourly | Yearly cost per person | Cost before | Cost after |
|---|---|---|---|---|---|---|
| Front desk (check in, check out, phones) | 6 | 4 | $15.75 | $46,800 | $280,800 | $187,200 |
| Prior authorization and referral coordinator | 2 | 0 | $26.48 | $78,683 | $157,367 | $0 |
| In house biller | 1 | 0 | $19.08 | $56,695 | $56,695 | $0 |
| Total | 9 | 4 |  |  | $494,862 | $187,200 |

Yearly cost per person is the Houston hourly rate times 2,080 hours, divided by 0.70 because wages make up 70% of total compensation in private industry (BLS, June 2026). The difference covers benefits and payroll taxes.

What other Houston family medicine practices can take from this

## Three gaps worth checking this week

### Write the problem visit as its own note section

A physical and a problem visit on the same day are both payable only when the record shows separate history, assessment and plan for the problem. One blended note gets the E/M bundled.

### Check G2211 on every Medicare follow up

Ongoing care for a chronic condition qualifies, and since 2025 it can sit on a modifier 25 visit beside a wellness visit or a vaccine.

### Track your approval rate by plan

Texas grants a prior authorization exemption at 90% approval over 12 months with state regulated plans. You cannot claim it if nobody is counting.

[Request a Revenue Defense Audit](https://webillhealth.com/audit) 

[Family medicine billing](https://webillhealth.com/specialized-rcm-advocacy-for-family-medicine) 

[Denial Defense 2.0](https://webillhealth.com/denial-defense-2-0/)

Your practice next

## See what your family medicine schedule is leaving unpaid

The Revenue Defense Audit runs the same counts on your claims: modifier 25 losses, authorization denials, coding level and patient balances. You get a written report that ranks each fix by dollars. We reply within one business day.

[Request a Revenue Defense Audit](https://webillhealth.com/audit) 

[Check my Revenue Defense Score](https://webillhealth.com/revenue-defense-score/)

Questions

## About this case study

Is this a specific client?

This is a worked example of a 12 provider family medicine group with two Houston area clinics. The payer list, coding rules, wage rates and workload figures come from the public sources listed on this page, and every result ties back to the practice profile above it.

How was the 29% counted?

Collections on new dates of service in month six ($464,916) against the baseline month ($360,400). Old A/R recovered during the takeover is left out, so the gain reflects what repeats every month.

Does the Texas gold card law remove prior authorization?

Only for plans regulated by the Texas Department of Insurance, and only for physicians with at least 90% of requests approved over the evaluation period. Since September 1, 2025 that period is 12 months with a minimum of five services. Medicare, Medicaid and self funded employer plans still require authorization.

What happens to modifier 25 under the CY2027 Medicare proposal?

CMS proposed paying 50% of an office E/M billed with modifier 25 on the same day as a procedure with a 0, 10 or 90 day global period. The comment period closed September 14, 2026 and the final rule has not been published. Documentation that clearly separates the problem visit from the procedure matters either way.

Sources

* [AMA 2025 Prior Authorization Physician Survey, May 13, 2026](https://www.ama-assn.org/press-center/ama-press-releases/ama-survey-prior-authorization-reform-pledge-falls-short-physicians)
* [Texas HHSC Medicaid and CHIP managed care service areas, January 2026](https://fhb.hhs.texas.gov/sites/default/files/documents/services/health/medicaid-chip/programs/managed-care-service-areas-map.pdf)
* [Texas Medical Association, 2025 gold card law refinements (HB 3812)](https://www.texmed.org/LegeWrapInsurance)
* [Texas Department of Insurance, prior authorization exemptions (HB 3459)](https://tdi.texas.gov/health/hb3459.html)
* [CMS Transmittal 13015, G2211 with modifier 25](https://www.cms.gov/files/document/r13015otn.pdf)
* [BLS, private industry compensation costs, June 2026](https://www.bls.gov/opub/ted/2026/compensation-costs-for-private-industry-workers-averaged-46-89-per-hour-worked-in-june-2026.htm)
* [Payscale, medical receptionist pay in Houston](https://www.payscale.com/research/US/Job=Medical_Receptionist/Hourly_Rate/e212a6e2/Houston-TX), [authorization specialist pay in Houston](https://www.payscale.com/research/US/Job=Authorization_Specialist/Hourly_Rate/e586f736/Houston-TX), [medical billing specialist pay in Houston](https://www.payscale.com/research/US/Job=Medical_Billing_Specialist/Hourly_Rate/8e5a480b/Houston-TX)
* [Physicians Practice, staffing benchmarks per physician](https://www.physicianspractice.com/view/how-many-staff-members-does-my-practice-actually-need-)

WeBill Health is a specialty focused revenue cycle management partner for independent practices. Request a Revenue Defense Audit at https://webillhealth.com/form/