Billing and revenue cycle
Billing work, with clear responsibilities and a record of what happens next.
For independent medical practices that want to replace a biller or share the work with HRI. We agree who handles eligibility, authorizations, claim submission, follow-up and payment posting before we begin.
- Health Revenue Intelligence, LLC
- A business associate agreement before any patient record
- Printed fees
- Status, next action and owner
Summary
What does HRI Med handle in billing?
HRI can handle billing or agreed parts of it: eligibility, authorizations, claim preparation, submission, follow-up and payment reconciliation. Your written scope identifies the claims and responsibilities included, and how status is shared.
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.
If an enrollment is missing, we identify what must be completed before billing that payer. You can ask HRI Med to handle new enrollment applications as a separate service; you do not have to buy our enrollment service to engage us for billing.
Agree which steps HRI will handle.
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.
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 claim in scope is checked against the payer's 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 are checked before submission and followed to a payment or written payer decision.
Payment posting and reconciliation
For work in scope, remittances are posted against claims and matched to the available deposit records. Payment differences and the next action are recorded.
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.
Other responsibilities to agree
- Patient benefit questions answered, so your front desk does not have to
- Second-level and external reviews taken on in writing when a first appeal fails
- A monthly reconciliation that ties payer payments to your bank deposits
Available on their own, priced in writing first
- Recovery projects on aged A/R, from a written claim list
- CAQH upkeep, re-credentialing and revalidation
- Payer contracting, with electronic claim and remittance (EDI and ERA) setup
A record of the work and the next action.
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.
Your status record groups claims by what happened to them. It identifies the next action and who is responsible. The reporting format and schedule are agreed with your practice.
Work status
| 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. |
How we handle denials.
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 prepare it with the relevant record, the payer's policy and the plan language. Further appeals are separately scoped and approved.
- 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 the CAQH profile that does not match the payer's file. Because we run enrollment too, we fix those at the source.
60%
of medical group leaders in an MGMA Stat poll said their claim denial rates had risen from the prior year.Source A below.
54%
of medical groups told an earlier MGMA Stat poll that credentialing-related denials were rising.Source B below.
Check payments against the available rate information.
For claims in scope, we compare paid amounts with the contract or published fee schedule available to us. We record differences, the follow-up required and the payer's response.
Payer notes connect recurring issues to the next claim or follow-up. They can also identify questions to address when a contract is reviewed.
Start with a billing review, or go straight to billing.
The agreement
The scope, the price and a business associate agreement, all in writing and signed before we see any patient information. If you start with the review, its fee is invoiced when you sign, and the work starts when it is paid.
Access
Access to your practice system and clearinghouse, set up under the agreement and limited to the work in scope.
Optional billing review
A separate paid project, $7,500 for one to three providers and $12,500 for four to ten, that starts from your report totals: each provider's enrollment with every payer, unpaid claims and denials, and a walk-through of eligibility, authorizations and charge entry. The written report recommends actions; you choose which work to buy. What it covers
The open claims
We read what is outstanding against each payer's filing limit and work the oldest recoverable claims first.
Changing billers or sharing the work
A handover with the work assigned.
Before the start date, we agree which work belongs to HRI, your staff and your current biller. Open claims and any separate recovery project are identified in the scope.
- Claims already submittedWho follows them, and which unresolved items transfer?
- New claimsWho prepares and sends them, and from which date?
- Denials and authorizationsWho handles open appeals and requests already in progress?
- Payments and recordsWho posts and reconciles remittances during the handover?
Existing unpaid claims are reviewed against filing limits. Aged A/R projects and further appeals are separately scoped. No patient records are needed for the initial inquiry.
Priced from your numbers, in writing.
We price billing as a flat fee per claim with a monthly minimum. Your proposal defines what counts as a billable claim, the responsibilities included, the contract term and any early-exit charge before you sign. It is never a percentage of what is billed or collected. Payers pay your practice directly, and we never receive, hold or direct their payments.
Billing runs for the term written in the agreement. If you end it early, an exit fee applies, set in the agreement from the monthly minimum and the length of the term. Your claim history and files are yours either way.
Consulting, enrollment and the written answer on a new service carry printed fees instead, listed on the pricing page.
What we need to price it.
- Claim mix
- The visits and procedures you bill most, in round numbers.
- Claims a month
- How many claims go out.
- Your payer list
- Every payer you bill.
- Practice software
- The system you schedule and bill in.
The request form asks for claims a month. Put the other three, and how many locations you run, in its message box. Rough ranges are fine.
Common questions before you change billers.
Can you take over from the biller we have now?
Yes, where the assignment fits. Before the start date, the handover plan identifies the payers, open claims and responsibilities that HRI will take on.
Will you work the denials and old claims we already have?
We can assess them for a defined assignment. Each payer sets its own filing limit, so we review the dates and available records before agreeing the work. We also work claims more than 90 days old as a project, at $250 an hour, on a written estimate first.
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 what that payer allows.
Sources
- MGMA Stat poll of medical group leaders on denial rates, 235 responses. Poll taken 2024.
- MGMA Stat poll on credentialing-related denials, 425 responses. Poll taken 2021.
Can we keep our current billing software?
Tell us which practice-management system, EHR and clearinghouse you use. We confirm the workflow and access needed before accepting the assignment.
Who finishes claims already with our current biller?
The handover plan assigns those claims before the start date. Existing claims do not automatically become part of a new billing engagement; the agreed scope identifies which work transfers.
Tell us where your claims stall.
Or that you have not sent one yet.
Say roughly how many claims go out each month and which payer denies the most.