Medical Billing
Charge entry through payment posting, run inside your system, with the claim followed until it pays or it is appealed.
What Is Included
Charge Entry
Charges entered from your encounter documentation, with missing-charge queries back to you.Claim Scrubbing
Claims checked against payer edits before they leave.Claim Submission
Submitted through your clearinghouse; rejections corrected and resubmitted.Payment Posting
Remits posted, underpayments flagged against the contracted rate.Patient Statements
Statements produced and sent. We do not run collections.Reporting
An agreed reporting package, on the cadence you set: charges, collections, AR by bucket and denial reasons.
How It Works
1. Documentation In
Signed encounter notes reach us on the agreed cadence, inside your system.
2. Charges and Scrubbing
Charges are entered, checked against payer edits and queried back to you where something is missing.
3. Submission and Rejections
Claims go out through your clearinghouse. Rejections are corrected and resubmitted.
4. Posting and Reporting
Remits are posted, underpayments flagged and the reporting package is delivered.
Medical Billing in Detail
Billing failures are quiet: a claim leaves, something comes back, and the gap disappears into aging.
A rejection means the claim never entered the payer's adjudication system. The clearinghouse or the payer's front-end edits found a formatting or data problem: an invalid member ID, a missing rendering provider, a date of birth that does not match the payer's file. The claim is returned unprocessed, and in most payers' rules it has not been "received" for timely filing purposes.
A denial means the claim was accepted, adjudicated and paid at zero, with a claim adjustment reason code stating why. The two are handled differently. Rejections are corrected and resubmitted. Denials are worked against their reason code, and some require an appeal with documentation attached.
Confusing the two is expensive in one direction: a rejection that sits in a clearinghouse work queue as if it were a denial can quietly pass the filing deadline while everyone assumes it is in process.
A rejection means the claim never entered the payer's adjudication system. The clearinghouse or the payer's front-end edits found a formatting or data problem: an invalid member ID, a missing rendering provider, a date of birth that does not match the payer's file. The claim is returned unprocessed, and in most payers' rules it has not been "received" for timely filing purposes.
A denial means the claim was accepted, adjudicated and paid at zero, with a claim adjustment reason code stating why. The two are handled differently. Rejections are corrected and resubmitted. Denials are worked against their reason code, and some require an appeal with documentation attached.
Confusing the two is expensive in one direction: a rejection that sits in a clearinghouse work queue as if it were a denial can quietly pass the filing deadline while everyone assumes it is in process.
Most delays on an otherwise correct claim come from data captured before the visit: a secondary insurance not recorded, a subscriber relationship entered wrong, an authorization number not attached to the claim line, or a referring provider required by the plan and left blank. Scrubbing catches the ones that payer edits can express; the rest come back as denials and are traced to the registration step that caused them.
Batch timing matters too. Claims held for weekly submission, or held for a coding backlog, age before they leave. Charges are entered as the documentation is signed, scrubbed and submitted in the next run, so the claim's clock starts as close to the date of service as the documentation allows.
Where a payer requires paper, records or a specific attachment type, that requirement is documented per payer so the claim goes out complete the first time rather than being pended for additional information.
A paid claim is not necessarily a correctly paid claim. The remittance advice (835) shows the allowed amount for each line. That figure is compared with the rate in the practice's contract and fee schedule for that payer and code. Where the allowed amount is below contract, the line is flagged at posting rather than accepted.
Common causes are an outdated fee schedule loaded at the payer, a modifier applied differently than the contract specifies, multiple-procedure reductions applied where they should not be, and bundling edits that the contract carves out. Each flagged line is queried with the payer with the contract language cited, and the outcome is tracked with the rest of the denial and appeal work.
Doing this requires the current fee schedules for each contracted payer. Where the practice does not have them on file, requesting them from the payer is one of the first onboarding tasks.
Access to the practice management and EHR system, provisioned per person with the permissions the work requires and nothing more. Access to the clearinghouse account and to payer portals, again provisioned by the practice so it can be revoked at any time.
Signed encounter documentation on an agreed cadence, and a named person who can answer missing-charge and documentation queries. Current payer contracts and fee schedules, or authority to request them. A decision-maker for proposed write-offs and adjustments.
Finally, an agreed reporting package and cadence: what is in it, who receives it, and when. For outsourced medical billing, this is set in the written scope before work starts, and revised only in writing.
Where This Sits in the Cycle
- Eligibility and Benefits Verification
- Prior Authorization
- Medical Coding
- Medical Billing
- Denial Management
- AR Follow-Up and Recovery
After AR Follow-Up and Recovery, the cycle returns to Eligibility and Benefits Verification.
Related Services
Medical Coding
Coding from your documentation, with queries back to you when the note does not support the code.Learn MoreDenial Management
Denials worked by reason code, corrected, appealed and tracked.Learn MoreAR Follow-Up and Recovery
Aged AR worked by bucket and payer, with recovery reported back to you.Learn MoreEligibility and Benefits Verification
Coverage, benefits and patient responsibility checked before the visit.Learn More
Hand Over Your Billing
Tell us your payer mix, claim volume and systems. We will come back with a written scope for billing.
- Charge Entry
- Claim Scrubbing
- Submission
- Payment Posting
- Underpayment Checks
- Patient Statements