Billing and revenue cycle
Every claim followed from the eligibility check to the deposit. Every denial traced to what caused it.
We run the revenue cycle for independent practices: benefits and eligibility, authorizations, claim build and follow-up, payment posting, denials and appeals. Each Friday you get it on one page, in plain words.
The review is free and needs no patient data.
Payer by payer.
Billing starts where enrollment ends.
A claim sent before a payer's effective date may never be paid. So we bill a payer once it has enrolled the practice and the provider, in writing. In a new practice, billing opens payer by payer as the dates arrive. In an established one, we take over the payers you bill today and check each enrollment on the way in.
Three habits run through it: prices in writing before work starts, status on a set day, and a written reason behind every number we report.
If your payers have not enrolled you yet, the Payer Enrollment Sprint comes first. It is the fastest way in, and billing picks up the file it leaves.
Every stage, one owner.
From the day a patient books to the day the money is matched.
Many unpaid claims were lost before they were sent, to a lapsed plan or a missing approval. So the work starts before the visit, and it ends only when each payment is matched to what the payer owed.
Benefits and eligibility
We confirm coverage for the date of service, the plan the patient carries today and what the patient owes, before the visit where the schedule allows it. A plan change caught at booking is a phone call; caught at denial, it is rework.
Authorizations
We check which services each plan wants approved first, request the approval with the documentation it asks for, and log the number against the visit.
Claim build
Each visit becomes a claim checked against the payer's own rules: the provider it has enrolled, the place of service, the codes and modifiers the note supports, and the diagnosis that carries them.
Submission and follow-up
Claims go out clean and are tracked until each one is paid or answered.
Payment posting and reconciliation
Every remittance is posted line by line against its claim, and every deposit is matched to the remittance behind it. A short payment shows up as a line, not as a gap in the bank balance nobody can explain.
Denials and appeals
Every denial is read before anything is resubmitted, and the cause decides the next move: a corrected claim, a written appeal or a fix upstream.
Same day, same page.
A working week, and one page on Friday.
Early in the week, coming visits are checked for coverage and approvals and last week's visits go out as claims. Remittances are posted as they arrive, each denial is opened as it lands, and quiet payers get a call.
On Friday you get the claim report. It groups claims by what happened to them. Where something went wrong, it names the cause and says who moves next.
Friday board
| Payer | What happened | Cause we found | Next move |
|---|---|---|---|
| Medicare | Paid as billed | Nothing to fix | UsPosted against each claim. |
| Commercial plan A | Denied | The payer still had the practice's old service address on file. | UsCorrected the record and resubmitted. |
| Commercial plan B | Denied | This plan wanted approval before the service. | YouBook this plan's patients after approval. We appealed with the note. |
| State Medicaid | Paid less than billed | Paid below the plan's own fee schedule for this code. | UsUnderpayment raised with the payer, with the schedule attached. |
| Commercial plan C | Waiting on the payer | Accepted, then silent. | UsCalled for status and logged the reference number. |
A sketch of the format. Your report carries your payers and your claims.
A denial is a symptom. We go after what caused it.
Send a denied claim back unchanged and the payer will usually deny it again. Every adjustment on a remittance carries a reason code, and the work begins there. We match it to the claim and the visit note, then decide which of three things the denial needs.
- A corrected claim
- When the fault is on the claim itself: a code, a modifier, a patient detail.
- An appeal
- When the claim was right and the payer was wrong. We write it with the note, the payer's own policy and the plan language attached, and we take it to the next level when the first answer is wrong too.
- A fix upstream
- When the same denial will keep coming back, say a provider missing from a payer's file or a service this plan wants approved first. We fix the source and tell you what changed.
In a new practice, some of the most stubborn denials lead back to enrollment: a provider not linked to the group, or an address in CAQH that does not match the payer's file. Because we run enrollment too, we fix those at the source.
60%
of medical group leaders told an MGMA Stat poll that their claim denial rates had risen over the year before.Source A below.
54%
of medical groups told an earlier MGMA Stat poll that credentialing-related denials were rising.Source B below.
What a paid claim hides.
A paid claim is not always a claim paid right.
A denial announces itself. An underpayment does not: the remittance says paid, and the shortfall sits inside a line nobody reads twice. We read every paid line against what that payer owes for that code, from your contract or its published fee schedule. A difference is raised with the payer and stays on the Friday board until it is settled.
Payer intelligence is what the claims teach us over time, written down for you. Which plans deny which codes, and why. Which want approvals the others do not. Which pay promptly, and which go quiet after accepting a claim. Where a plan's rate for a service sits below what the work costs you to deliver. It shapes the next claim before it goes out, and it gives you the facts for a contract renewal.
A review first, then a plan written for your payers.
The free review
A conversation from a one-page checklist: which payers you bill, where claims stall today, what is open and ageing. No patient data.
The agreement
The scope, the price and a business associate agreement, all in writing and signed before we see any patient information.
Access
Access to your practice system and clearinghouse, set up under the agreement and limited to the work in scope.
The open claims
We read what is outstanding against each payer's filing limit and work the oldest recoverable claims first.
Priced from your numbers, in writing.
You will not find a billing percentage on this site. The price depends on your claim volume, your payers and how much of the work stays in your office. A number printed before we have seen those would be a guess, so it is set in the agreement after the review.
Enrollment and the written answer on a new service carry printed fees instead, listed on the pricing page.
The four numbers we need to price it, and why.
- Monthly collections
- What the practice collects in a typical month, in round numbers. It sets the scale of posting and reconciliation.
- Claims a month
- How many claims go out. It sets the weekly workload, from claim build to follow-up.
- Your payer list
- Every payer you bill. Each one has its own rules, its own forms and its own denial habits.
- Practice software
- The system you schedule and bill in. It decides whether we work inside it or alongside it.
Put them in your request, even as rough ranges, and the review starts from them. The price comes back to you in writing.
What owners ask before they hand over their claims.
Can you take over from the biller we have now?
Yes. We start with the review, look at what is open and ageing, and plan the switch payer by payer so no claim is left without an owner.
Will you work the denials and old claims we already have?
Bring them to the review. Each payer sets its own filing limit, so we read the dates before we promise anything.
Do we keep our front desk and our coder?
That is your call, and it shapes the price. Some practices keep eligibility checks or coding in house and hand us the rest. The agreement names who does what.
Will you bill a payer before its effective date?
No. We hold those claims, show you which visits fall before the date and tell you plainly what that payer allows.
Sources
- MGMA Stat poll of medical group leaders on denial rates, 235 responses.
- MGMA Stat poll on credentialing-related denials, 425 responses. A single-question pulse poll of MGMA members, and the older of the two.
Tell us where your claims stall.
Or that you have not sent one yet. The review needs no patient data.
We get back to you as quickly as possible.