Patient registration and demographics
Capture full demographics, insurance card front and back, secondary coverage, and a current address. 70% of denials trace back to errors here.
Everything that happens between a patient walking in and money landing in your bank account: coding, eligibility, claim submission, denials, A/R, and the KPIs that separate practices that get paid from those that don't.
Medical billing is the operational pipeline that translates a clinical encounter into paid revenue. Every patient visit triggers a sequence: verify coverage, document care, code procedures and diagnoses, submit a claim, post payment, transfer balance to the patient, follow up on denials. Each step has rules, deadlines, and failure modes. When billing works, your practice gets paid in 30 days. When it doesn't, your A/R aging report tells the story.
This guide walks the full pipeline. Each section links to a deeper page if you want the operational details. If a term is unfamiliar, the billing glossary defines 77 of the ones that matter.
Healthy practices hit every stage on time. Aging A/R usually traces back to a stage that broke.
Capture full demographics, insurance card front and back, secondary coverage, and a current address. 70% of denials trace back to errors here.
Real-time check of active coverage, deductible status, copay, and OOP max before the visit. Skipping this stage is the cheapest way to lose revenue.
How verification works at MHBPayer pre-approval for services that require it (imaging, surgeries, certain meds, DME). No auth equals no payment, often unrecoverable.
The clinical encounter becomes CPT, ICD-10, CDT, and HCPCS codes plus modifiers. Documentation must support every code billed.
Inside our coding workflowThe 837 EDI claim goes through a clearinghouse to the payer. Pre-submission scrubbing catches the avoidable errors.
End-to-end billing at MHBERAs auto-post; paper EOBs are scanned and posted within one business day. Variance reports flag underpayments against contracted fee schedules.
After insurance pays, the patient balance generates a statement with one-tap pay. Payment plans handle larger balances.
Patient payment processingDenials get worked, appealed, escalated. Aged claims get triaged before timely filing closes. Root-cause feedback prevents repeat denials.
How A/R recovery worksEvery claim needs a procedure code (what was done), a diagnosis code (why it was done), and often modifiers (how it was done differently). Get any of them wrong and the claim denies.
Outpatient and physician procedures, maintained by the AMA, updated annually. Five-digit codes that describe what was done.
Justify medical necessity. Codes are 3 to 7 characters. Specificity matters – vague codes cause denials.
Maintained by the ADA. All codes start with D. Used for every dental claim.
J-codes for drugs administered in office, A-codes for transport, plus durable medical equipment and supplies.
-25 (separate E/M), -59 (distinct procedure), -76 (repeat), -95 (telehealth), and dozens more.
Specialty deep dives: medical billing · dental billing · medical coding
Eligibility verification is the cheapest, highest-leverage step in the whole cycle. A 60-second real-time check catches inactive plans, exhausted benefits, and prior auth requirements before the visit. Skipping it produces denial reasons CARC 22 (covered by another payer), CARC 27 (after termination), and CARC 197 (precertification absent), which together account for a meaningful share of all denials in most practices.
Prior auth has its own playbook: identify the requirement at scheduling, initiate the request, follow up daily, document the auth number with expiration, and chase recerts before expiration.
Every denial has a CARC and often a RARC. The codes tell you what to fix. Recovering one claim is good; preventing the next 100 of the same denial type is better.
Almost always preventable with real-time verification at check-in.
PreventablePreventable with auth tracking. Sometimes appealable when the service was urgent.
Mostly preventableAppealable with documentation, LCD/NCD reference, and clinical rationale.
AppealableOften correctable. Bundling may need modifier -59 or an X-modifier.
CorrectableUsually unrecoverable. Monitor aging buckets so claims never sit this long.
UnrecoverableWithout active in-network status, claims either deny or pay at out-of-network rates. New providers need 60 to 120 days for full credentialing across major payers. Existing providers need re-credentialing every 36 months for most commercial payers, every 60 months for Medicare. Lapses pause cash flow.
The work involves CAQH ProView attestation every 120 days, Medicare PECOS forms (855I, 855B, 855R, 855O), state Medicaid enrollments, and per-payer commercial applications.
If your biller can't produce these numbers, they're not measuring – which means they're not managing.
Payments / (charges - contractual adjustments - bad debt). The single best measure of revenue cycle health.
How long money sits in A/R before being collected. Trending up means something broke upstream.
Percent of claims paid on first submission with no further work. Below 90% means scrubbing or eligibility is leaking.
Percent of claims denied. Track total rate and top CARC reasons by payer.
Claims that pass scrubbing and reach the payer error-free. Closely related to first-pass.
How A/R is distributed across 0–30, 31–60, 61–90, 91–180, 181+ buckets.
Days from date of service to charge entry. Long lag means long delay before claim leaves the building.
The eight stages apply everywhere, but the failure modes shift by specialty.
90832/90834/90837 progress notes, telehealth modifier 95/FQ/93, parity law appeals, Medicaid behavioral carve-outs.
State Medicaid map, sealant and fluoride coding, EPSDT, OR billing crossover, age-based eligibility rules.
Multi-NPI billing, multi-state credentialing, M&A support, consolidated reporting for groups.
Cardiology, ortho, derm, primary care, pain, podiatry, PT, and 60+ more. Each with its own playbook.
The honest math, not the sales pitch.
Math works when volume is large and stable enough to justify two or more dedicated FTEs and you have a manager who can supervise them.
Math works when collections variance, hiring difficulty, or denial volume make in-house unstable.
The honest version: most practices under $5M in collections do better outsourcing. Most over $20M can do either. The middle is judgment-dependent.
If they can't answer any of these directly, keep shopping.
What's your guaranteed turnaround on charge entry and claim submission?
Show me a recent client's monthly KPI dashboard – net collection rate, days in A/R, denial rate.
Who actually works my account? Names, titles, certifications.
What's your appeal-success rate on denied claims, and how do you measure it?
If we end the relationship, what's the data handoff process? Do we keep our A/R?
Are charges based on collections or submitted? (Submitted-based fees can hide write-offs.)
What's your BAA, security posture, and breach notification policy?
Will you train my front desk on eligibility, charge capture, and patient collections?
Direct answers to what practice owners ask most.
Electronic Medicare Part B claims pay in 14 days on average, with a 14-day floor mandated by CMS. Paper claims take 29 days. If your Medicare claims are aging past 30 days, the issue is usually a kickout (NCCI edit, modifier, or missing PECOS enrollment) rather than payer slowness.
Coding is the act of translating clinical documentation into CPT, ICD-10, CDT, and HCPCS codes plus modifiers. Billing is the operational pipeline that uses those codes to generate, submit, and follow up on claims. Some practices have one team; others split them. We staff certified coders (CPC, CCS, CPMA) separately from billing operations.
Ask for last month's net collection rate (target 96%+), days in A/R (target 28 to 45 depending on specialty), denial rate (target under 5%), and aging bucket mix (70%+ should be in 0 to 30 days). If they can't produce those numbers, they're not measuring – which means they're not managing.
Depends on volume and stability. A 4-provider primary care practice doing $1.2M in collections typically spends $130K to $180K fully loaded on two in-house billers plus a coder and software. Outsourcing the same practice at 6% of collections is $72K. The math flips at higher volume with stable hiring. Below $5M in collections, outsourcing usually wins on cost and stability.
Most claims past timely filing are unrecoverable absent a specific exception (provider error, payer error, retroactive eligibility, COB confusion). The lost revenue should not show up on your bill from a percentage-of-collections billing partner; if it does, that's a contract you should renegotiate or exit.
For out-of-network emergency services and certain non-emergency services at in-network facilities, you can't balance bill the patient. Disputes with the payer go through federal IDR. For most outpatient practices, the practical impact is on patient communication (good-faith estimates for uninsured / self-pay) and on out-of-network providers in narrow disputes. We screen claims for NSA scope and route disputed payments through IDR when warranted.
Standard onboarding runs 2 to 4 weeks, depending on EHR/PM access and how clean current credentialing is. Aged A/R cleanup runs in parallel with new-claim work; we don't make you wait. Schedule a call to scope your transition.
Reading about KPIs is one thing. Seeing yours is another. Free billing audit takes 30 minutes and you walk away with your real net collection rate, denial rate, and aging mix – whether you sign with us or not.
30-minute free billing audit. We'll surface the leaks (undercoding, denials never appealed, eligibility errors) and quantify the dollars you can recover this quarter.
