Outsourced Medical Billing Services
Outsourced Medical Billing Services: What we actually run for a practice
Five workstreams. Most practices start with one, and the order below is the order we usually recommend, because each one stops a leak the next one cannot fix.
Claims and charge capture
Charges coded and submitted inside 48 hours of the encounter, scrubbed against the payer’s own edits before they leave, with the clearinghouse rejection queue worked daily rather than weekly.
Denial management and appeals
Every denial sorted by reason code and worked to its actual cause. Administrative denials get corrected and resubmitted, clinical denials get a peer to peer where the payer offers one, and the rest get an appeal that argues the stated reason rather than restating the claim.
Prior authorization
Requirement checks at scheduling rather than after the visit, clinical packets built to each payer’s evidence list, and every approval logged with its units, visit caps and expiry date so renewals start before the authorisation lapses.
Credentialing and enrollment
Payer enrollment, CAQH maintenance, revalidation calendars and the Medicare and Medicaid applications that have to be complete before a single claim can be paid. A clinician seeing patients under an enrollment that is not active is working for free.
Accounts receivable recovery
Everything past the first thirty days worked by age bucket: unpaid claims chased, underpayments compared against contract, credit balances resolved, and old A/R triaged into what is worth pursuing and what is genuinely dead.
Reporting you can act on
A monthly view of charges, payments, adjustments and the denial breakdown by reason and by payer. Not a dashboard to admire, but the number that tells you which of the five workstreams above is currently behind.
The order the work goes in
Sequence matters more than effort. Done in the wrong order, the same work produces denials instead of payments.
If a payer has the clinician enrolled under the wrong specialty, every claim from that payer is at risk regardless of how well it is coded. This is checked first because nothing downstream can compensate for it.
Denials sorted by reason code show where the money is actually going. Practices usually expect a coding problem and find an authorization or eligibility problem instead, which is a different fix entirely.
Authorization moved to scheduling stops denials that no appeal can recover cheaply, because the service is either approved before delivery or never delivered unauthorised.
Appeals written against the actual denial reason win far more often than appeals that restate the clinical story. The reason code is the instruction.
Recovering the 30 to 90 day bucket is cheaper than recovering anything older, so it is worked first even though the older balances are larger.
How this compares
| What changes | In-house, no process | With MedFactor |
|---|---|---|
| Charge lag | Charges batched and entered at week end | Coded and submitted within 48 hours of the encounter |
| Denial ownership | Whoever has time, usually after the second notice | One named owner per payer, worked to the reason code |
| Authorizations | Discovered when the claim denies | Verified at scheduling, units and expiry tracked |
| Enrollment | Handled when someone notices a claim was not paid | Revalidation calendar with CAQH maintained monthly |
| A/R over 90 days | Not worked, written off at year end | Triaged by age and collectability, worked deliberately |
| Reporting | What the practice management system happens to show | Denial breakdown by reason and payer, monthly |
Services by specialty
The work above runs differently depending on what the practice actually bills for. These pages cover the specifics.
Common questions about outsourced billing
Pricing is a percentage of collections for most practices, which means we are paid when the practice is paid. That aligns the incentive properly but it also means the percentage depends on specialty, volume, payer mix and how much work is currently broken. A practice with clean claims and one with a 90-day A/R backlog are not the same job, so we quote after the audit rather than before it.
Yes. We work in the practice management system you already use and submit through your existing clearinghouse wherever possible, because switching systems mid-stream creates the very revenue gap we were hired to close. Where the system is genuinely the bottleneck, we will say so and explain what it is costing, but that is a separate conversation from running the billing.
Denial and A/R recovery shows up in the first 30 to 60 days, because that work is on claims already delivered. Charge capture and coding changes take a full billing cycle to appear, since a claim submitted today is paid on the payer’s schedule rather than ours. Enrollment fixes have the longest lag, because a payer application takes what it takes.
That is your decision, not ours. Practices with a strong front office usually keep charge entry and patient contact in house and move the payer-facing work out. Practices with no billing team hand over the whole cycle. We do not ask to replace people as a condition of working together.
We work under a signed business associate agreement, access is role-limited, and PHI stays inside the systems it already lives in rather than being copied into shared drives or spreadsheets. The team works remotely with access scoped to the accounts the practice authorises, and access is revoked when an engagement ends.
No long-term contract is required. Billing relationships end for good reasons, including the practice hiring a full-time biller once volume justifies it. A short notice period in either direction is enough, and the practice keeps its data, its clearinghouse and its payer relationships throughout.
Billing by state and metro
Payer mix, Medicaid program names and enrollment rules change at the state line, so these pages are specific to the market rather than generic.
Find out where the money is leaking before you commit to anything
Send us ninety days of remittance advice and your top payers. We will sort the denials by reason code and tell you which of the five workstreams above is actually behind, then what we would change first.
Request a free billing audit Call (480) 599-9904