When you’re looking for a medical billing company, it’s not simply a matter of cost or the number of services they offer. In a medical practice, the billing partner is an integral part of the billing function of the practice. Its work can impact the timeliness of claims, denials processing, outstanding AR recovery, and practice owners’ understanding of their revenue cycle.

This also depends significantly on the healthcare organization’s type. A single doctor might need reliable Billing and AR solutions without the high cost of an enterprise platform. As more doctors join the practice, coding, credentialing, denial management, reporting and multi-provider support may be required. Health systems and hospitals have a much greater number of transactions along with more complex revenue-cycle needs.

Therefore, no single medical billing company will work for every practice in the same manner. Instead, it is best to evaluate companies based on their services, the type of healthcare organization they are designed to serve, their specialty experience, the technology they offer, reporting capabilities, scalability, and pricing structure.

Here are five medical billing and revenue cycle companies that are more closely examined, then a look at the services that practices can expect, the types of pricing models they might experience and other reasons why one billing partner may be the better fit for a practice.

There are top medical billing companies in the USA that offer the best services.

1. HMS USA

Medical billing and revenue cycle management services are offered by HMS USA to medical practices. They also help with medical coding, credentialing, payer enrollment, denial management, accounts receivable, and insurance workflows.

The company’s service philosophy is based on the belief that medical billing should not end with the claim submission. Claims must still be followed up after they are out of the practice, payments must be posted properly, denials must be reviewed and accounts must be followed up on regularly.

For practices that have a need for more extensive support, HMS USA can integrate multiple of these revenue cycle functions into one revenue cycle relationship. This is especially advantageous for organizations that are not interested in handling their own vendors for billing, coding, credentialing and AR recovery.

The billing workflow can encompass the key phases of the revenue cycle, including the review of patient and insurance data, claims processing, posting of payments, follow-up of denials, and accounts receivable management. The extent of the services will vary according to what is specified within the practice’s agreement.

HMS USA also has provider credentialing and payer enrollment programs. It may be significant for practices that are gaining providers, enrolling in new insurance networks or keeping their current provider participation.

One other factor is specialty expertise. Medical billing isn’t the same from specialty to specialty. Requirements for coding, authorizing, documenting, and payers vary greatly depending on the type of practice. A pain management practice may have very different coding, authorization, documentation and payer requirements than a behavioral health provider, cardiology group or surgical practice. When choosing a service package, a practice should talk to the billing company about the specialty of that practice and the type of billers it uses.

Independent Physicians, Small and Mid Sized Physician Practices, Specialty Physician Practices, Multi Provider Physician Groups and Organizations interested in a more comprehensive RCM model beyond just claim submission may be more interested in HMS USA.

Billing is not the only critical question that a potential customer might have regarding HMS USA. It is where does the practice wish to place the responsibility on the outside team and where does it want to retain the responsibility within the practice itself.

2. CareCloud

Revenue cycle management, healthcare technology and practice-management solutions come together in CareCloud. This model is therefore applicable to practices interested in billing and administrative and clinical technology to function closely together.

It can include activities like patient registration, eligibility verification, charge capture, coding, claims processing, denial management, payment posting, accounts receivable follow-up, patient billing, and reporting.

CareCloud’s technology-centric approach is one of its more significant factors. New practices are more focused on finding an outsource billing team that integrates into their existing systems. There are those who wish to have a more integrated environment in which practice management, billing, reporting and other administrative duties are linked.

CareCloud is moving toward that latter “model”.

That may be beneficial for practices that want to minimize the number of separated administrative systems to use. A centralized workflow can also provide management with the ability to see the claims, payments, denials, and financial performance.

Convenience and integration may be an attraction for smaller practices. Increasing numbers, the easier it is to manage more providers and locations with a connected platform makes it more important.

However, practices should first assess how well the platform will fit into their workflow prior to switching to an integrated platform. Technology transformations may impact scheduling, documentation, billing, reporting and staff training too, so the transition process should be taken into account along with the billing service itself.

3. athenahealth

Another significant health care technology and revenue cycle firm that supports physician practices and bigger health care organizations is athecentralhealthenahealth.

It is a multi-stage revenue cycle model that operates throughout the patient financial journey. These may involve registration, insurance eligibility, authorization management, charge capture, coding, denying claims, payment posting, and financial reporting.

Integrating healthcare technology with revenue-cycle operations is a cornerstone of athenahealth’s operations. The key in the model is to not look at billing as an “isolated back-office” job, but to tie it in with clinical and administrative tasks, and then financial tasks.

This may be useful for practices who desire a technology landscape in one location.

Registration or insurance issues, for instance, can ultimately turn into claim issues. Where those systems are linked, the organization has a better chance of determining that’s where the problem began rather than just fixing the denied claim.

The overall scale of athenahealth is relevant to practices beyond those of small independent practices. Reporting, workflow management and financial supervision needs can differ between multi-provider/multi-location organizations and a single-provider office.

The main concern for any practice considering athenahealth is whether or not their technology and RCM model align with the business’ operational needs. A practice interested in maintaining the same relationship might take a different view than a practice that is already considering a technology change.

4. R1

R1 operates in a different segment of the revenue cycle market from many physician-office billing companies.

It’s primarily about large-scale healthcare revenue cycle operations, technology, automation, analytics and financial transformation. The company collaborates with healthcare organizations that may have complex revenue-cycle environments and have significant claim volumes.

This distinction is significant if comparing R1 with a company specifically geared towards small medical practices.

For a two-doctor practice, the major requirement is coding, claims, payment posting, denials and AR follow-up. A large health system might require revenue-cycle operations everywhere from hospitals to outpatient centers, a variety of specialties, significant accounts and large amounts of payers.

This larger operating context is the basis for R1’s model.

It’s also focused on technology and automation. In the case of large organizations, there may be a lot of financial and claims data, and automation and analytics are playing an increasingly important role in detecting issues and handling work at scale.

In hospitals and health systems, it’s not if they can submit a claim that they’re asking. It is if the seller can run a complicated financial transaction with multiple facilities and revenues.

R1 is thus more aptly suited to enterprise-level revenue cycle needs and large healthcare organizations and hospital systems than to a small independent physician practice seeking to implement an outsourced billing department for basic needs.

5. Medical Billers and Coders (MBC)

Medical Billers and Coders (MBC) offer medical billing and coding services, credentialing, AR management, denial management and other revenue cycle services.

The company also emphasizes specialty-specific billing, which is crucial for practices that provide procedures or services for which there are specific coding and documentation needs.

While medical billing is typically marketed as a single service, its process can differ significantly, depending on the specialty. The coding needs for a cardiology practice are not the same as behavioral health, pain management, orthopedic or gastroenterology practices.

As a result, a billing company with special expertise may be better equipped to anticipate frequent coding and payer errors before they turn into issues.

MBC services include claim submission services, payment posting services, AR follow-up services, denial management services, coding services, credentialing services, and reporting services.

The process of credentialing is especially important in practices that are new to the field or have been seeking to expand their number of payers. If the provider is not properly enrolled with the payer, it can cause billing issues, unrelated to the quality of the claim itself.

When physician practices, specialty groups, ambulatory organizations and healthcare providers are seeking a balance of billing, coding, credentialing and revenue-cycle support, MBC is a viable choice.

Like any billing company, practices need to make sure that the team handling their billing has hands-on experience with their specialty, payer mix, software and claim volume.

How We Evaluated the Top Medical Billing Companies

We researched the best medical billing companies by carrying out the following steps:

When comparing medical billing firms, don’t just look at the number of services the firm offers, or even the size of the firm itself.

A business may be very good with enterprise revenue cycle administration but not at all a requirement for a small actual worth health care provider. A different provider could offer excellent specialty billing expertise, but not have the technology. Thus, the full operating model must be a part of the right evaluation.

Medical Billing Services

First, one needs to look at the real scope of billing services.

There are many different interpretations of the term “medical billing,” depending on the company. For one vendor, it might simply be a claim submission process. Then again, it may be coding, payment posting, denials, AR follow-up, patient statements, eligibility verification, and reporting.

A practice should ask a detailed description of what the monthly fee covers.

This prevents one of the usual issues a company might have, which is the initial low cost but then the services they didn’t expect have an added fee.

Revenue Cycle Management Expertise

RCM is an expertise of the revenue cycle.

RCM is a more comprehensive approach to the financial process.

RCM is not just about paying claims, but it’s about the entire process from patient registration to final reimbursement.

Even with a good billing team, a practice can miss the revenue due to incorrect insurance eligibility checks, missed authorizations, incorrect charges, and failure to follow-up on old AR.

A good RCM partner should be able to see these links.

Medical Coding Capabilities

Claim quality goes hand-in-hand with coding accuracy.

A billing company should have a procedure for the review of ICD-10-CM diagnosis codes, CPT procedure codes, HCPCS codes (where applicable), modifiers and supporting documentation.

Here, specialty expertise is in particular key. Someone who has experience with the coding protocols and documentation requirements of a specific practice is more likely to be able to identify documentation gaps and coding problems than a coder who is only used to dealing with general billing.

But the question that should be asked is not only one of whether the company has certified coders or not. Inquire about how your providers have worked with them in the past.

Denial and AR Management

Avoidance and AR management.

One of the most obvious distinctions between basic billing and active RCM is in denial management.

If a claim is denied, there has to be a reason for the denial and a course of action for the future.

In some cases, the claim must be amended. In some cases more documentation may be needed. In other cases, an appeal might be the best option. If the denial continues, there is a process that needs to be explored.

The same applies to accounts receivable as well.

The Practice should not be expected to interpret an aging report provided by a billing company. The team should actively pursue outstanding accounts and provide detail on major trends.

Specialty-Specific Experience

Specific experience can be a significant factor.

A practice should discuss with another practice how many providers in their specialty the company supports and the nature of services provided.

For instance, billing for interventional pain procedures may have other documentation and authorization requirements compared with a typical outpatient primary care visit.

Likewise, each of the other specialties has its own billing issues: behavioral health, surgery, cardiology, gastroenterology, and others.

A vendor should be able to explain these in practical terms, not just list a lot of specialties on their website, since this is where people will find out.

Technology and EHR Integration

The integration of technology and using EHRs. The use of technology and EHRs.

One of the key elements that are part of the assessment is technology compatibility.

The billing company may have to coordinate with the practice’s existing practice management system, clearinghouse, payer portals and reporting systems as well as its current EHR.

In some businesses, the technology they build is the centerpiece of their business. Others utilize a variety of systems that are currently in use at healthcare practices.

Both models are not the right model for everyone.

The big question will be whether the technology will simplify or complicate the billing process.

Reporting and Revenue Visibility

The ability to report on the revenue visibility.

If a practice doesn’t know what’s going on, they can’t effectively manage revenue cycle.

The reporting useful should enable management to understand claims, payments, denials, AR aging, payer performance and collection activity.

The most effective reports are those that are not too lengthy!

A practice owner should be able to see, based on a report, what has changed, where money is lost and what is in need of attention.

Scalability and Practice Size

The size of the practice and its scalability

The size and growth rate of the practice should be matched to that of the billing company.

One doctor might be vastly different to a 100 doctor company.

As a practice expands, more providers, providers’ locations, provider specialties, provider payer contracts, reporting levels and administrative duties may be necessary.

The billing relationship should be flexible to accommodate the practice’s growth.

Medical Billing Services Offered by Leading RCM Companies

The leading RCM companies provide medical billing services that are very beneficial.

Medical billing firms generally tend to have various names for its plans, but the service provided and the revenue cycle is generally the same.

When it comes to comparing proposals, a practice’s understanding of these services makes it easier.

Full-Service Medical Billing

The major financial activities associated with submitting and collecting claims are often included in full-service billing.

This can involve charge entry, coding, claim submission, payment posting, denial management, AR follow-up, patient billing and reporting, depending on the agreement.

Full-service must be verified with the contract. A practice should never take it for granted that all of the billing related functions are included.

Medical Coding Services

Medical coding is the process of converting medical services provided to patients into medical diagnosis and procedure codes.

This is typically ICD-10-CM and CPT coding, modifier review and documentation assessment for professional claims.

If a coding error occurs, it can result in a denied claim or rejected claim and can be a compliance issue.

Practices should, therefore, consider coding accuracy and the accuracy of their billing company’s work, as well as its regular quality checks and coding team’s ability to keep up with applicable requirements.

Claims Management

Claims management starts before the claim is submitted.

The process may involve examining charges, verifying coding, verifying claims information, sending claims, tracking the claim, correcting rejected claims, and following up for claims not paid.

A good claims process doesn’t view submitting claims as the end of the billing team’s job, but as one part of a bigger process.

Denial Management and Appeals

Denied claims need to be reviewed according to the reason for denial.

A billing team may be needed in order to make corrections, offer proof, submit an updated claim, or prepare an appeal.

There is a larger opportunity in discerning pattern.

If the same payer continues to deny a specific service due to missing authorization, then it’s time for the practice to make a workflow change, not send another appeal six weeks later.

Accounts Receivable Follow-Up

Accounts Receivable is money that has not been received.

Follow-up for AR is more than just checking the age of an account. The billing team should take into account who is paying, the balance, claim status, filing cut-off, claim denial history, and the chance of claiming recovery.

High dollar claims may be more worthy of attention than low dollar claims which are unlikely to ever be recovered.

Insurance Verification

By verifying insurance coverage, insurance verification can help clarify if a patient has insurance coverage and what the financial requirements and restrictions are.

Verification can determine eligibility, benefits, deductibles, copayments, coinsurance, network status and other payer requirements.

It’s important to get this right when the car is first bought, and can save you issues later on.

Prior Authorization

For services that need to be pre-authorized by the payer, prior authorization may be a vital component of the revenue cycle.

This process can involve verification of requirements, gathering of documents, presenting the request, tracking the authorization, and delivering results.

The practice should determine if the billing company covers the entire authorization process or if it only does administrative support.

Payment Posting

Payment posting records transactions relating to insurance payments, patient payments, contractual adjustments, and more.

Reliable accounts receivable system by accurate posting.

This can create inaccurate balances and financial reports in the practice.

Patient Statement Management

Even with an insurance policy, the patient may still have a financial obligation.

Patient statement management can include statement generation, maintaining statement balances, answering billing inquiries, and arranging payment.

Some vendors may provide these services for free in their billing fee and others may charge separately.

Provider Credentialing

The ability to bill insurance plans may be directly impacted by credentialing.

This includes initial enrollment, recredentialing, maintaining CAQH, applying to payers, rostering, and tracking enrollment.

If credentialing is needed for a new practice or expanding group, it should be managed in conjunction with the entire revenue-cycle strategy.

Revenue Cycle Management

These activities are all consolidated under RCM.

The goal is to gain insight into the interdependencies between the front-end process, coding, claims, payments, denials, and AR.

A practice might find, for example, that a significant percentage of their denial situation is related to registration or eligibility errors in the first place.

Therefore, a comprehensive RCM strategy can prove more beneficial than examining the billings alone.

Medical Billing Audits

When you perform a billing audit, you will get a chance to review the existing revenue-cycle process in advance of problems becoming more costly.

An audit can provide an examination of coding, charge capture, payment posting, denials, AR aging, payer contracts, documentation and compliance processes.

An initial audit may also provide a baseline to measure the performance of a new billing company for practice that are considering adopting a new billing company.

Choosing the Right Medical Billing Company for your Practice!

The answer lies in the practice and not in the marketing of the company.

The billing partner that is ideal for a solo provider isn’t necessarily the right choice for a large health system.

Medical Billing Companies for Solo Physicians

You can find medical billing firms for solo doctors online. There are medical billing firms that are available online for solo doctors.

For solo doctors, a strong billing system is essential but should not be cumbersome.

Responsiveness, coding accuracy, claim follow-up, AR management, reporting and easy pricing are typically the most critical factors.

The doctor should also be able to identify in a hurry who to call about the billing problem.

Medical Billing Companies for Small Practices

If you are a small practice, there are medical billing firms that can help you.

In some cases, the employees in a small practice are playing multiple roles.

The office manager also has to perform a variety of tasks such as scheduling, eligibility, patient communication, billing questions and more.

One way to free up that work load is to outsource billing and let internal staff concentrate on patient care.

The secret lies in finding out just what work the billing business will actually do.

Medical Billing Companies for Multi-Provider Practices

The more providers, the more detailed reporting is required.

A multi-provider practice might require to compare collections, denials, AR and claim performance by provider, location and payer.

A billing company should have the ability to report in this manner.

Medical Billing Companies for Multi-Specialty Practices

Billing teams in multi-specialty organizations have to grasp all the different workflows for clinical processes.

It is not as if the billing rules could simply be applied to all specialties.

A practice should inquire if the vendor has specific or experienced personnel for each specialty a practice offers.

Medical Billing Companies for Hospitals and Health Systems

Hospitals and health systems are just larger in scope.

They could be operating many facilities, deal with thousands of claims, have intricate payer contracts, multiple specialties and hefty financial reporting criteria.

This is a time when an enterprise RCM provider like R1 could be more applicable than a smaller physician-office billing company.

Medical Billing Companies for Specialty Practices

Specialty Practices are available in the medical billing firms.

Qualifications and experience are more important for specialty practices.

Inquire from prospective vendors about how they typically work, diagnose and categorize cases, authorization requirements, payer issues, and denial patterns in your specialty.

A business that is familiar with your niche should be able to discuss these terms without using the generic billing terminology.

Medical Billing Companies for Behavioral Health Practices

There’s a documentation, authorization, coding, and payer requirement to behavioral health billing.

When looking for the vendor, a behavioral health practice should request specific feedback on his or her experience with the types of services that the practice provides and with the service mix.

General healthcare experience is desirable, but specialty specific experience may be more beneficial.

Medical Billing Companies for Practices Wishing for fully outsourced RCM

Before signing, practices that are looking into full outsourcing should make sure to understand what full RCM actually entails.

Who will be responsible for eligibility, coding, claims, payment posting, denials, AR, patient billing, reporting and credentialing should be explained in the agreement.

The more the vendor is being delegated, the more the concept of “accountability” becomes paramount.

Medical Billing Companies for Practices That Need Billing Software and RCM

For practices that require billing software and RCM, there are Medical Billing Companies which can help with billing services. There are Medical Billing Companies for practices that need billing software and RCM.

Some practices desire to keep their current technology and outsource their billing.

Others are willing to transition to an integrated platform.

CareCloud and athenahealth are examples of organizations where healthcare technology and revenue cycle services are closely connected. Other billing companies are more interested in integrating with the systems a practice already uses.

The best option is based on the facilities and receptivity of the practice.

How Much Do Medical Billing Companies Charge?

Comparing the price of medical billing is not as straightforward as simple percentage vs. percentage.

Two companies can be priced at different rates, but offer different amounts of service.

The percentage does not always represent the lower cost, however, if any of the elements of coding, credentialing, AR recovery, patient billing, or other services are billed separately.

Percentage-Based Medical Billing Fees

In certain cases, the fee may be a percentage of the patient’s bill.

Percentage based pricing generally bases the billing on an agreed upon percentage of collections or other specified level of revenue.

The contract should clearly specify what is covered in the calculation.

Practices should define how patient payments and secondary insurance, old AR, workers’ compensation, and other revenue sources are treated.

Depending on the meaning attributed to the word collections, the real costs may vary.

Flat-Fee Medical Billing Pricing

A Flat fee model is a billing model that involves a fixed fee for billing service.

This can help with monthly budgeting as the practice is aware of what they will be spending.

What happens when the practise expands is the key question.

If the number of providers, provider locations, or claims grows significantly, the contract should clarify whether fees are adjusted accordingly.

Per-Claim Billing Fees

A per claim pricing model means that the vendor bills by the number of claims handled.

This could be a viable option for practices that have a predictable number of claims.

The practice should consider whether claims and claim adjustments, rejected claims and claim adjustments, secondary claims and claim adjustments, and resubmissions can be distinguished separately.

It should also specify if denial management and AR follow-up are provided.

Hybrid Medical Billing and Pricing Models

Hybrid pricing is a combination of 2 or more pricing methods.

For instance, one vendor may have a base fee, and then extra charges for some of its services.

This can be flexible but the contract becomes particularly important.

The practice should work out the approximate monthly price based on the Claim Volume and service required for that practice and not just on the advertised starting price.

What does a billing company normally include in its cost?

No single list of services would encompass all fees in all billing rates.

One company could provide coding, payment posting, denial management and AR follow-up.

One may charge for credentialing, patient statements, old AR or otherwise.

Discuss scope of work in writing before signing.

The proposal should ensure that ownership of different key points of the revenue cycle are identified.

Additional Costs to Ask About Before Signing

Before signing you should ask some of these additional questions:

Cost of implementation and of transition should be discussed with prices as well.

Inquire about any alternative charges for technology integration, clearinghouse services, credentialing, coding audits, old AR recovery, patient statements, additional providers, additional locations, or special reporting.

The provisions for termination of contract are also of interest.

A practice should be aware of the length of the initial contract, the notice, any early termination fees, who will own payment history, and who is responsible for the outstanding AR at the conclusion of the practice.

The quickest method to compare offers is to take a look at the overall cost.

Analyze the differences between what you offer, what you get, who does what, how you’re being measured, and how easily the relationship can be expanded as your practice expands.

This is a far more accurate view of a medical billing firm’s worth than comparing the billing percentages.

In-House vs. Outsourced Medical Billing

There are two options when it comes to medical billing – In-House vs. Outsourced Medical Billing.

Whether to hire their own billing staff or outsource to a medical billing company is a decision that needs to be made regarding the nature of their operations. Both types of models are possible, but their requirements for technology, staffing, costs, and management are significantly different as well as their capacity for scalability.

It might sound easier to have all these functions onsite at first, but for a small practice, it could be simpler. Billing can, however, turn into a full department as volume increases, with a need for trained billers, certified coders, managers, software, payer follow-up, denials and training.

Cost of In-House Medical Billing

Payroll is one thing and the obvious drawback of having an in-house billing department is the wages of the people working there.

Other practice considerations may include benefits, recruiting, training, paid leave, management time, billing software, clearinghouse fees, computers, office space, compliance training, and continuing education.

Then there’s turnover expense. An experienced biller is not just an employee that is lost. It can forget about payment procedures, claims in process, past AR, recurring payment denials, and workflows unique to the practice.

If your practice is very small and has a reasonable claim volume an internal employee might be enough. As the billings become more involved the practice should look at the total cost of the department instead of the employee’s salary.

Benefits of Outsourcing Medical Billing

Outsourcing medical billing offers a number of benefits. There are several advantages to outsourcing medical billing.

Outsourcing is a practice that outsources some or all of the billing duties to an external specialist team.

Instead of having to hire separately for each of these roles, the practice could hire them all from one vendor: billers, coders, denial specialists, AR staff, credentialing personnel, and account management.

The other benefit is specialization. A claims or payer processing company works with claims and payer processes on a daily basis. This experience can be helpful in the event of repeated denial, aged AR, coding questions, payer mandates and billing process changes.

Outsourcing also can lighten the administrative load of physicians and practice managers. However, they can still monitor the revenue cycle without having to be in the billing department all day.

But it isn’t a foregone conclusion that outsourcing will yield greater profits. The importance of the vendor, breadth of services, reporting, communication and practice-specific experience remains.

Medical Billing Staff and Technology Costs

People are not enough for an internal billing operation.

A practice might require a practice management system, coding resources, clearinghouse connection, payer portals, reporting tools, security measures, a computer and more technology.

The in-house team has to be continually educated as well. Payer policies change. Guidelines for coding are revised. Software changes. New providers and services generate new billing requirements.

An outsource billing company distributes numerous of these operational resources among his clientele. Generally, the practice does not build all the components in-house but takes money for the agreed service.

But it’s important for practices to confirm what the new technologies are in an outsourcing deal. Some vendors provide this technology and reporting at no extra cost; some may require fees for this.

Scalability and Practice Growth

When growth happens, vulnerabilities in an internal billing model can come to light.

This is a practice that begins with two providers and ends up with ten providers, several locations, more specialties and significantly more claim volume. The billing department must keep pace with it.

This can involve recruitment, implementing extra levels of management, technology upgrades, and new workflows.

Outsourced billing firm can supply resources without the practice having to hire all of the extra staff.

This is especially helpful for growing practices, new providers, new provider locations, and new specialties.

The big question is: Can the vendor’s infrastructure handle that growth? Before signing a long-term contract, a practice should ask how extra providers, clinics and even more claims are treated.

Control, Reporting, and Revenue Visibility

Control is one factor that can keep billing in-house.

The practice has access to its staff and be able to adjust processes on the spot. However, the opposite is not always true: that is, direct control does not imply improved visibility.

It may be difficult for internal department with less structured RCM reporting to give financial visibility compared to an outsourced team with structured RCM reporting.

Effective billing relationships enable practice leadership to have insight into claims, collections, denials, AR aging, payer performance, and uncollected accounts.

There should be proper access to financial and billing information, as well.

Do not sacrifice control over your business by outsourcing. The vendor will do the day-to-day running of the business, and practice leadership will keep an eye on operational performance and business decisions.

When is Outsourcing Medical Billing a Good Idea?

Billing may be outsourced if it becomes challenging to bill in-house, when AR is rising, when denials are not consistently followed up on, or when practice staff are spending excessive time tracking bills.

It can also be used if a practice is expanding and aren’t looking for an increased billing staff in parallel.

This doesn’t mean a practice that has a good staff on board doesn’t need to outsource all of its services. A hybrid model, where front office and some billing are performed internally and coding, AR, credentialing or denial management are outsourced, is also used by some organizations.

This will depend on the volume of the practice, the specialty, staffing, technology, budget, and management ability.

What to Look for in a Medical Billing Company

When picking a medical billing company, you should look for the following features:

Billers are more than price-cutters, they’re a vendor selection.

The company will be responsible for a large part of the revenue cycle in the practice and will be given sensitive financial and patient information. So, the evaluation should be on billing performance as well as operational fit.

Specialty-Specific Billing Experience

One of the initial questions to ask is specialty experience.

The level of expertise in interventional pain procedures, behavioral health services, surgery, cardiology, gastroenterology or other workflows may differ in a company that focuses primarily on primary care.

Elicit your vendors’ responses to questions about what kind of services they do.

The discussion should not be limited to whether or not the company “supports” your specialty. Inquire about their common denials, the documentation issues that arise and the ways in which they resolve payer issues unique to your practice.

Medical Coders and Billers with Experience in Medical Coding and Billing

The employees of the account are as important as the company.

Inquire if the coding is done in house or back to another organization. Know who will review coding, how the quality of the coding will be checked and if the coding is done by the coder who has experience in the specialty of the practice.

The billing staff should be knowledgeable of more than just bill submission. They can research rejected claims, understand why rejected claims are rejected, follow up on unpaid claims, and see common issues.

Strong Denial Management

Denial management should not be an add-on.

Inquire about the company’s categorization of denials and the frequency with which management is getting denial reports.

A helpful denial process discerns patterns. The billing team should research the reason for the repeated denial of the same service by a specific payer.

The objective is not just to capture more claims, but to appeal more claims. It’s to ensure that denials won’t keep going where they could be avoided.

Effective AR Follow-Up

An old AR needs some “tending.”

Inquire about the frequency of outstanding accounts being worked, how their company prioritizes claims with high dollar and how they deal with claims that are nearing timely filing or appeal deadlines.

An important thing to know is what will happen to old AR when you move your business to a different billing company.

There are vendors who put special emphasis on new claims and current billing. Some provide special AR cleaning services. This distinction should be captured prior to implementation.

Integrating EHR with Practice Management System

How to integrate EHR and Practice Management System.

The billing company needs to be able to communicate and collaborate with the technology that your practice currently has or state what needs to be changed.

Request information about your EHR, practice management system, clearinghouse, payer portals, and reporting systems.

Switching over to technology can make the change much easier to make.

How information is exchanged between the practice and the billing company is another important question to ask. Staff can be unnecessarily wasting time by manually exporting, emailing or re-entering information again and again, which can lead to errors.

Transparent Reporting

A billing company must ensure that the management is able to gain understanding of the financial status of the practice.

Reports should be realistic and not too complicated.

Useful reporting can include collections, claims, denial trends, AR aging, payer performance, payment posting, and more revenue cycle metrics, depending upon the agreement.

Request a sample report prior to signing.

That will be more of a learning experience than a sales presentation.

Dedicated Account Management

The presence of a designated point of contact can be a large help.

If there’s a question about billing, the practice should be aware of who is responsible for answering it.

Inquire from the account manager about his/her sole responsibility for the practice, frequency of client team meetings and what steps will be taken to resolve escalations.

It shouldn’t be necessary for a practice to tell its entire billing history to a new rep each time an issue arises.

HIPAA-Compliant Processes

Medical billing firms manage safeguarded health details, which is why privacy and security ought to be a part of the vendor evaluation.

Practice should be aware of how patient information is accessed, transmitted, stored and protected.

If pertinent, the business associate relationship and documentation should be examined as part of the contracting process.

Don’t just assume a vendor is “HIPAA compliant;” ask them to prove it. Inquire on its real security and privacy systems.

Clear Pricing and Contract Terms

It’s important to have clear pricing and contract terms.

Price should be clear prior to signing.

Find out how the billing fee is calculated, what services it covers and what services incur extra charges.

The contract should also cover the following: initial term; renewal terms; notice of termination; transition responsibilities; access to and the handling of outstanding accounts upon termination.

It’s not always the most helpful to have a low starting price if there are hidden expenses later in the contract.

Proven Transition and Onboarding Process

There exists a proven Transition and Onboarding Process. A Transition and Onboarding Process is in place and proven.

The transition to a new billing company may be disruptive when not handled smoothly.

A professional onboarding process should create a process for who will collect the credentials, who will move the data, who will review the open claims, who will set up systems, and who will communicate with the practice.

The vendor should also describe existing AR—how it will be handled.

Ask a realistic time frame for their practice to implement the contract and what services their staff will have to offer.

Questions to Ask Before You Hire a Medical Billing Company

The sales call is the easiest part of selecting a billing company. The more helpful the conversation, once operational questions are raised.

Have You Had Experience in My Medical Specialty?

Instead of a general listing of specialties, request specific examples.

For those who are practicing pain management, inquire about injections, procedures, authorization, modifiers, and common payer questions.

If you run a behavioral health practice, inquire about the company’s services, coding needs, and the workflows with payers.

The aim is to see if the vendor has an understanding of your real billing situation.

What Is Covered in Your RCM Fee?

Have the answer in writing.

Specifically inquire about coding, charge entry, claims, payment posting, denial management, AR follow-up, patient statements, eligibility, authorizations, credentialing, and reporting.

Be careful not to go by the same definition of “full RCM” in every company.

What Do You Do When a Claim Is Denied?

What if a denial comes, ask what happens then?

Who reviews it? How fast is it given? Who decides to correct it or to appeal? How is the recurring denial patterns reported?

The process of a vendor should be clearly explained.

How to Reduce Aged Accounts Receivable?

Request the company’s AR procedure.

It is important to be aware of how older accounts are handled, how often they are worked and how they are updated for management.

If you have a lot of aging AR, from your practice, inquire if the vendor will work that AR and if it’s part of the quoted amount.

Which Billing & Practice Management Systems Do You Support?

Give the vendor specific systems that your practice employs.

Next, inquire about how the billing team interfaces with those systems and if there is any other technology needed.

This is particularly important for organizations that are transitioning from their internal billing department to an external business.

How Often Will We Get RCM Reports?

There is no single reporting schedule that is suitable for all practices.

Some organisations require to produce operational reporting on a regular basis, whereas others might want to have a management review on a monthly basis.

It is important that the reporting schedule and contents are agreed.

Request to see samples of reports before signing.

Will We Have a Dedicated Account Manager?

Who will deal with the relationship?

Inquire about whether the account manager works with several clients, if it is possible to meet with the account manager on a regular basis, and who will take care of the escalated billing issues.

Many frustrations are avoided if a clear communication structure is established.

How to Safeguard Patient and Practice Data?

Inquire about the method in which patient information is conveyed, stored, and retrieved.

Before providing access to systems where there is protected health information, the practice should be made aware of the vendor’s privacy and security practices and confirm that the applicable contractual requirements are understood.

What Will Change in the Transition From Our Current Billing Team?

Request a plan for a step-by-step transition.

This includes open claims, unpaid balances, credentials, patient balances, reports, payer portals, and billing software as well as historical data.

The vendor should also provide details on how it will ensure that claims are not missed during the transition.

What Are the Contract Conditions and the Rules for Its End?

Don’t wait till the end of negotiations to discuss the terms of contract.

Discuss initiation, renewal, termination notice, early termination, data ownership and responsibilities after termination.

The practice should have a clear idea of what it will do if the relationship doesn’t work out.

Common Mistakes Practices Make When Selecting a Medical Billing Company

Some of the mistakes that people make when selecting a medical billing company are listed below.

A sales presentation can make a billing company appear great, but be the wrong fit for the operation.

There are a number of common errors that come up over and over again when practices assess vendors.

Choosing Based Only on the “Lowest Price”

While price is important, it shouldn’t be the only one.

Some of these services, such as coding, AR follow-up, denial management, credentialing, patient billing, or reporting, may be excluded from a cheaper billing service.

Look at the total service package not just at the percentage.

Ignoring Specialty Experience

While a general billing background is helpful, some specialized knowledge can be important as well.

Your vendor should be familiar with your procedures, documentation, payer requirements and payer denial patterns.

Refusing to Read the Contract

A verbal agreement isn’t sufficient.

It should include the services that will be offered, fees, responsibilities, reporting, access to data, termination provisions, and transition process.

Failing to Ask About Denial Management

Claims are not worth anything just because they’re filed.

Ask what they think would happen if they were not allowed.

If a vendor does not have a clear denial workflow, then it is time to take a closer look.

Overlooking Aged Accounts Receivable

But a practice can be doing well with billing on the up and down right have a big AR problem.

Request information on how old balances will be handled and who will be responsible to collect them.

Not Checking the Compatibility of Technology

Billing companies that do not have the ability to communicate effectively with the practice can actually increase administrative work.

Checks for technology compatibility prior to implementation.

Accepting Limited Reporting

If a simple collections number is provided monthly, it may be challenging to determine what the changes in revenue are a result of.

Reporting should be sufficiently detailed to enable claims and denials, AR and payment, and key trends to be understood.

Not Defining Who Owns the Billing Data

The practice should be aware of what rights it has to its billing and financial records.

It is extra important if the relationship comes to an end.

Access to the data and transition responsibilities should not be negotiated during an emergency, but should be discussed in the contract.

Signs That You May Need to Change Medical Billing Companies

There are signs that you may need to change medical billing companies.

Migrating billing companies isn’t a decision to be taken lightly. Transitions are a process that takes time and careful management.

However, there can be risks to continuing with a bad vendor.

Increasing Claim Denials

If the denial rate is increasing, it’s possible that there are issues with coding, authorization, eligibility, documentation, payer configuration, or claims submission.

Consider the reasons for rejection beyond the percentage.

Growing Accounts Receivable

When AR is not explained or there is no recovery program, it should be looked at if it is getting older.

A billing firm ought to be able to tell you the place your money is and what is being done concerning it.

Poor Communication

A billing partner shouldn’t walk away when things go wrong.

Failing to provide timely responses, unclear responsibility, and changes in who the account representative is can make revenue cycle management unnecessarily complicated.

Limited Revenue Reporting

When you don’t know what collections, denials, AR aging and payer performance are, you are not running your business with full information.

Reporting doesn’t have to be complex. It must be of service.

Slow Claim Follow-Up

Unpaid claims must be addressed in a timely manner.

When claims are nearing payer deadlines or appeal timelines, delays can get more severe.

Inquire if the billing firm has processes in place for follow-up and measurable accountability.

Significant Errors in Coding and Billing

Errors in one point of the billing relationship do not necessarily reflect a failure in the billing relationship.

Errors that occur over and over again, such as with the same services, providers or payers, are different.

If a problem occurs on a regular basis then a review of the root cause should take place.

Failure to Be Familiar With Specialty Knowledge

If your billing staff is constantly asking the same questions related to your specialty, or they can’t explain basic questions about the specialty, it’s a sign that the practice might not be getting the specialty-specific know-how it needs.

Unusual Billing or Contract Terms

When unexpected charges enter an outsourcing relationship, they can impact on the economics of the relationship.

If the practice starts to find that it has to pay extra for services it believed would be covered by the contract, it may be time to re-evaluate the contract and the value of the contract.

Third-Party Medical Billing vs. Full-Service Revenue Cycle Management

The third-party medical billing and full-service RCM services debate is a complicated one. The third-party medical billing and full-service RCM services issue is a complex one.

Third-party medical billing is sometimes mistaken for revenue cycle management (RCM), but they may refer to a different extent of services.

Let’s start by understanding what third party medical billing is.

What Is Third-Party Medical Billing?

Third party medical billing is a process that involves utilizing an external business to conduct billing tasks instead of the business doing the billing work entirely within its own business.

This can be specific or general.

One business may only be responsible for claim submission and payment posting. The other may be used for coding, denials, AR, eligibility and other functions.

The scope is actually determined by the terms of the contract.

What Is Full-Service RCM?

Full-service RCM does more than just handle the receipt of payment for services.

It can handle front-end functions like registration and eligibility, middle-end functions like coding and claim submission, and back-end functions like payment posting, denial management, AR follow-up and patient collections.

The goal is to work through the revenue cycle as a single cohesive process.

Key Differences Between Third-Party Billing and RCM

There are significant differences between third-party billing and RCM. Third-party billing and RCM are not the same.

The difference is in scope.

Third-party billing refers to the ones carrying out the billing, and RCM refers to the extent of revenue cycle management.

A practice doesn’t have to outsource the entirety of its revenue cycle, just its billing.

The practice could, for instance, keep eligibility verification, authorization, claims, payment posting, and AR tasks in-house and pass AR, claims, and payment posting details to an outside billing firm.

Another practice might delegate nearly all of the financial process.

Which Model Fits the Different Practice Needs?

If you have a highly experienced front office and only need to outsource the back end billing, then a small practice is an ideal choice.

As an organization expands, it could find that the problems they face at registration, eligibility, authorization, coding and claims can impact each other and may need wider RCM assistance.

Enterprise-level RCM capabilities, analytics, automation and multi-facility support might be needed with large healthcare organizations.

The right model is one that suits the problems that the practice is attempting to solve.

How Medical Billing Companies Improve Revenue Cycle Performance

The role of Medical Billing Companies in boosting the earnings cycle efficiency. The part that Medical Billing Companies Play in the earnings cycle efficiency.

An RCM company’s worth should be evident from the quality and consistency of the revenue cycle.

This does not mean that all vendors can provide a guaranteed increase in collections. Results are contingent on payer mix, specialty, documentation, reimbursement agreements, claim volume, existing AR and current billing function and operation of the practice.

Improving Clean Claim Submission

The key to clean claims is accurate information.

Demographic information, insurance details, coding, modifiers, provider details, and more claim elements can be reviewed prior to claiming.

The goal is to minimize avoidable rejections and to avoid claims going through the denial process if they can.

Reducing Preventable Denials

Denial management gets more valuable when it’s going upstream.

The billing team should determine if there is a pattern of denials due to eligibility, authorization, coding, or documentation problems, and then review the practice’s workflow with them to correct the problem.

Recovering Aged Accounts Receivable

Agreed AR is the money that has not been collected.

Older and unpaid accounts and those with higher balances and higher recovery potential can be prioritized by experienced AR teams.

It should be systematic and not based on any account that happens to be the first one on a work queue.

Improving the Accuracy of Payment Posting

When payment posting is done correctly it means that the financial record of the practice will accurately reflect what the payer actually paid.

It also assists in determining inconsistencies like under-payments, adjustments that have not been made, outstanding patient balances, and more.

If payment posting is an issue, it can cause the remainder of the revenue cycle to be more difficult to manage because management is relying on inaccurate data.

Identifying Revenue Leakage

There are various revenue leakage scenarios.

It might be possible that charges are not captured. The service can be incorrectly coded. Claims may be denied. The payments could be credited to the wrong account. Old accounts might not get much follow up.

An effective RCM review will take a holistic view of the entire process rather than assuming all problems start with a claim.

Improving Billing and Coding Processes

Billing companies can assist practices to recognize repeating mistakes and set up more uniform processes.

This could be code reviews, documentation comments, claim editing, procedure requirements by payers, or training.

How it is done varies based on the specialty and practice procedures.

Providing Better Revenue Cycle Visibility

Management requires information that it can trust to make financial decisions.

An effective RCM reporting system can provide information on what has been billed, what should have been paid, what isn’t, what is outstanding, and where there’s a need for extra attention.

Good billing work does not rely on visibility, but it is greatly facilitated.

Common Misconceptions About Medical Billing Companies

The medical billing company is responsible for a lot of things.

A medical billing company takes care of aspects of the financial and administrative procedures involved in healthcare claims.

Services can range from coding, charge entry, claim submission, payment posting, denial management, AR follow-up, patient billing, eligibility verification, credentialing, and reporting.

The range is quite wide from company to company; practices should take the time to read the service agreement carefully.

What Is the Cost of Medical Billing Outsourcing?

The cost of these varies.

There are several different pricing models that medical billing companies can use, such as percentage-based, flat-fee, per-claim, and hybrid pricing.

The final cost will vary based on specialty, claim volume, number of providers, services included, AR requirements, coding needs and technology.

Comparing is best done by comparing the total cost of the full service package and not a singular advertised rate.

Should Medical Billing Services Be Outsourced?

Outsourcing may be a good option when the expenses and management overhead of the in-house billing solution are more than the value.

It can be especially helpful for a practice that is experiencing increasing AR, ongoing denials, staffing issues, or a lack of in-house billing skills.

The outcome, however, will be based on the vendor’s performance and the practice’s particular situation.

What to Look for in a Medical Billing Company?

The first step is to determine what you really need outsourced.

Next, check companies’ specialties, services offered, coding skills, denial management, AR follow up, technology, reporting, communication, pricing, security, and contract requirements.

Request references or relevant experience as applicable and a clear scope of work before signing.

What Services Should a Medical Billing Company Supply?

The vendor should know if he or she will be handling claim submission, payment posting, denial management and AR follow-up at a minimum.

Other services provided by the practice could involve coding, eligibility, prior authorization, credentialing, patient billing, reporting, audits, and full RCM services depending on the practice’s needs.

There’s no one size fits all package. The key is that there is a clear definition of responsibilities.

Do Medical Billing Companies Abide by HIPAA?

Medical billing companies that deal with the protected health information are expected to fulfill the requirements of HIPAA.

Practices must continue to carry out suitable due diligence of the vendor.

Inquire about the protection of patient information, its access, how information is shared and any agreements or security protocols set in place.

Differentiating Medical Billing From RCM

In general, medical billing is about billing claims and cashing checks.

RCM is more comprehensive. Can cover front-end activities like registration and eligibility, coding and claim submission, and back-end activities like payment posting, denial management, AR, and patient collections.

RCM considers the interaction of all of these processes.

Will a Medical Billing Company Be Able to Function With My Current EHR?

There are a number of billing companies that will be capable of working with existing EHR and practice-management systems, with some compatibility issues.

Make sure that you give the vendor the software and clearinghouse details you use in your practice.

Discuss the connection of systems and if there are any other software or implementation tasks to be done.

What Is the Turnaround Time to Change Medical Billing Companies?

The timeframe will vary and be determined by the size of the practice, the software used, the number of claims, the payer mix, the amount of AR that exists, and the complexity of the transition.

A simple doctor’s office might have an easier time than an organization that has lots of AR outstanding across multiple locations.

The vendor should offer an implementation plan that details responsibilities, milestones, data needs, and the anticipated go-live procedure.

When to Change Billing Companies in a Practice?

Examples of when a practice should consider changing may include persistent billing issues, increasing denials, increasing AR, lack of communication, poor reporting, frequent coding mistakes, and unexpected expenses.

Management then needs to capture the issues that were present and see whether these issues can be realistically fixed under the agreement.

The practice should make careful plans for open claims, AR, data transfer, and access to the system and information related to the payer, if it is decided to transition.

Some Final Thoughts on Selecting a Medical Billing Company

Choosing a medical billing partner should be based on how well you think they’ll fit into your operations, not their marketing jargon.

Specialty Expertise

Select a company that comprehends the services that your providers are rendering, and the payer issues that impact your specialty.

Service Coverage

Specify which aspects of the revenue cycle the vendor will manage and what is done in-house.

Technology and Integration

Ensure that the company’s systems will support your EHR, practice-management software, clearinghouse, and reporting needs.

Reporting and Transparency

By now, you should have the knowledge you need to know about collections, denials, AR, claims, and other trends in the revenue cycle.

Pricing and Contract Terms

Is there a better deal to be had? Can you find a better price or contract?

Make a comparison of the full service price. Take a look at other fees, length of contract, termination conditions, ownership of data, and transition conditions before signing.

Communication and Account Support

To communicate and provide Account Support.

Find out who is responsible for your account, how soon complaints will be taken higher and how many times your staff will be in touch with the billing firm.

Long-Term Practice Fit

The greatest billing relationship is one that remains operational throughout the evolution of the practice.

A single practitioner can turn into a multi-provider group. Services may be added to a specialty practice. If the company is expanding, more outlets might be added.

Your billing partner should be able to accommodate those changes without making the revenue cycle more complex.