Medical Billing Services

Front End

• Insurance eligibility & benefits verification
• Authorization support
• Patient information validation

Mid Cycle

• Charge posting & CPT coding
• Documentation review & coding
• Claim preparation and scrubbing
• Clean claim submission

Back End

• Denial management & appeals
• Payment posting & ERA
• Insurance AR follow-up
• Patient AR & collections
• Underpayment identification
• Reporting & analytics

One Partner, Every Stage

Practices can engage us for the full revenue cycle or for a single stage that’s underperforming. Either way, we start the same place: a free RCM Audit that tells you exactly where the current process is losing revenue before we propose a solution.

The Revenue Cycle, Front to Back

A claim is only as good as the work done before it is created. Most denials and write-offs trace back to a step that happened days or weeks earlier, often by a different person than the one who sees the denial. The sequence below is the path a typical outpatient professional claim follows, and the point at which each step commonly goes wrong.

1. Scheduling and pre-registrationCapture the patient’s demographics, insurance card images, subscriber details, referring provider and visit type. Wrong subscriber IDs, misspelled names and missing secondary coverage at this point are among the most common causes of later rejections.
2. Eligibility and benefits verificationConfirm active coverage, plan type, copay, deductible and coinsurance, usually through an X12 270/271 transaction or the payer portal. Coverage should be checked before each scheduled visit, not only at the first one, because coverage changes monthly for many patients.
3. Authorization and referralsDetermine whether the planned service needs prior authorization or a referral, obtain it, and record the authorization number, approved codes, units and date range. Authorization is tied to the payer, the service and often the rendering provider.
4. Check-in and point-of-service collectionCollect copays and any estimated patient responsibility, and obtain signed consents and assignment of benefits. Balances that are not collected at the visit generally cost more to collect later.
5. Clinical documentationThe provider documents the encounter. The note must support the diagnoses, the level of service and the medical necessity of anything billed. Documentation gaps found after the claim is paid become audit and recoupment risk.
6. CodingAssign ICD-10-CM diagnoses and CPT or HCPCS Level II procedure codes, with the correct modifiers, based on the documentation. Codes must be linked to the right diagnosis pointers and follow NCCI edits and payer policy.
7. Charge entryEnter charges with the correct provider, place of service, units and fee schedule. The gap between date of service and charge entry (charge lag) delays every dollar that follows.
8. Claim scrubbing and submissionRun claims through edits for payer rules, required fields and code pairs, then submit electronically to the clearinghouse or payer on an X12 837 transaction (837P for professional claims). Review the clearinghouse acknowledgments (999 and the 277CA claim acknowledgment) and fix rejections the same day.
9. Claim status follow-upFor claims that are accepted but not yet paid, check status through the 276/277 transaction or payer portal, rather than waiting for the aging report to flag them.
10. Payment posting and reconciliationPost payments and adjustments from the electronic remittance advice (835 ERA) or paper EOB, using the claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs). Reconcile posted totals to the bank deposit or EFT.
11. Denials and appealsWork denials by root cause, correct and resubmit what can be fixed, and appeal what was wrongly denied inside the payer’s appeal window.
12. Secondary billing and patient balancesBill secondary or tertiary payers, transfer the remaining balance to the patient, and run statements, payment plans and collection workflows.
13. Reporting and management reviewMeasure the cycle with KPIs, find where it is slowing or leaking, and feed the findings back to the front end and to the clinical team. See Medical Billing Reports & Analytics.

Who Owns What, and Where the Handoffs Are

Revenue-cycle failures concentrate at handoffs: front desk to coder, provider to coder, biller to payer, payer to poster. The table shows a typical division of responsibility when a practice works with an outsourced billing partner. The exact split is agreed in the engagement and varies by practice and by how much of the front end the practice keeps in-house.

Common Failure Points by Stage

Where a denial is worked is rarely where it was caused. Mapping common denial reasons back to the stage that created them is the fastest way to decide where to invest effort.

CO means the payer assigns financial responsibility to the provider (contractual obligation). PR means patient responsibility, for example PR-1 (deductible), PR-2 (coinsurance) and PR-3 (copay). CO-45 is the contractual adjustment that appears on most paid claims and is not a denial by itself.

Payer Rules That Shape the Workflow

• Timely filing. Medicare generally requires claims within 12 months of the date of service. Commercial and Medicaid plans commonly set much shorter limits, often in the range of 90 to 365 days, and they vary by contract. Corrected claims and secondary claims can have separate limits.
• Appeal windows. Medicare redetermination, the first level of appeal, generally must be requested within 120 days of the initial determination. Commercial plans often allow 60 to 180 days, depending on the contract and plan type. Missing the window usually ends the right to appeal.
• Coordination of benefits. The primary payer must adjudicate before a secondary payer will consider the claim. For children covered by both parents, many plans use the birthday rule to set the order. Medicare Secondary Payer rules add further cases.
• Corrected claims versus new claims. A claim that was already accepted and paid or denied generally needs a corrected claim with the right claim frequency code rather than a new submission, which would be denied as a duplicate.
• Clearinghouse versus payer rejection. A rejection means the claim never entered adjudication and can be fixed and resent. A denial means the payer adjudicated it, and the remedy is a corrected claim or an appeal.
• HIPAA. Any billing partner that creates, receives or stores protected health information on a practice’s behalf is a business associate and must sign a business associate agreement. Access should follow the minimum-necessary standard, and electronic transactions follow the HIPAA X12 standards.

The Metrics That Run the Cycle

Managers do not need dozens of numbers, but they do need a short set that is calculated the same way every month. The figures below are commonly cited industry targets and vary by specialty, payer mix and patient volume, so they are starting points for a conversation, not promises.

• Days in AR = total accounts receivable divided by average daily charges over a stated period (for example, the last 90 days).
• Net collection rate = payments divided by (charges minus contractual adjustments), shown as a percentage. Bad debt and non-contractual write-offs reduce it.
• Clean-claim rate = claims accepted by the payer on first submission without edits or rework, divided by claims submitted.
• Initial denial rate = claims denied on first adjudication divided by claims adjudicated. Track it by count and by dollars.
• Charge lag = days from date of service to charge entry. Long charge lag delays cash and increases timely-filing exposure.
• Percent of AR over 90 days = AR aged beyond 90 days divided by total AR. This is a leading indicator of write-offs.

Each KPI should have one definition, one data source and one owner. For the full report catalog and how managers use each one, see Medical Billing Reports & Analytics.

When to Outsource the Whole Cycle and When to Outsource One Stage

The right scope depends on where the cycle is actually failing, which is why an audit comes first. As general guidance:

• Single stage suits a practice whose front end and clinical documentation are solid but whose back end is backing up, for example rising denials or unworked AR. Denial management and AR follow-up are common first stages.
• Mid-cycle focus suits a practice with clean registration but frequent coding or charge-capture problems. Start with documentation review and charge posting.
• Full cycle suits practices that are growing, adding providers or locations, or that no longer have the staff or in-house expertise to manage payers and rules across the whole sequence.
• Hybrid keeps registration and copay collection at the front desk, where the patient is present, and moves coding through reporting to a partner.

In any model, the practice keeps the clinical documentation, the financial policies it sets for patients, and the final decision on write-offs and appeals strategy. A good partnership makes those decisions easier by putting accurate data in front of the people who own them.