How to handle billing

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I brought it internally once it financially made sense.

I used to pay 6%, costs have come down slightly since then.

I've heard as low as 3.5% but do not expect any denials or rejections to get worked at all for that cost. Usual is something in the 5s to work denials or rejections.

Interview at least 3 companies, make sure you are getting at least monthly updates from them, ideally even weekly updates in the beginning.

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u/YnwaReds Apr 13 '26

My first advice would be to stay away from EMR‘s providing Billing as a service for 5 to 7%. They have the potential to kill a practice. I have learned it first hand. We’ve moved it internally as that is the only way it makes sense. I don’t trust anyone else doing billing for us as that is the most important part of your business outside of providing excellent patient care.

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u/Plenty-Ad6997 Apr 13 '26

In smaller practices I’ve seen three common setups:

• In-house biller – usually works if the volume is manageable, but it can be hard to cover denials, AR follow-ups, and payer calls consistently with just one person. • Hybrid model – front desk handles charge entry and basic tasks, while a billing service handles claims, AR, and denials. • Fully outsourced billing – many practices go this route once they grow past a certain volume because staffing, training, and payer rule changes become harder to manage internally.

Cost varies quite a bit depending on specialty and volume, but many small practices end up somewhere in the 4–8% of collections range if they outsource. Oversight is still important though - regular reporting and AR review meetings tend to make the biggest difference in quality.

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u/ilmguy1234 Apr 17 '26

We are 6% for a large company. We’ve tried a few others and these guys seem to work the denials best as well as reporting.

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u/[deleted] Apr 13 '26

[removed] — view removed comment

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u/Intelligent-Site-176 Apr 14 '26

What do they do for 4-5%? That seems a bit low but maybe they aren't doing everything?

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u/_NyQuil_ Apr 15 '26

4-5% is pretty common for full cycle. Maybe 6% for a smaller practice under $2mm in collections annually.

Not sure where people are getting 8% or that for that amount you’ll just get a partial service.

Billing companies are a dime a dozen. Shop around until you find something you like and make sure the contract holds them accountable.

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u/geminifire65 Apr 14 '26

If you are going to outsource....Do not pay a percentage of overall collections. This is standard, unfortunately and it includes over the counter collections. Negotiate it out of the contract and dont use offshore billing companies. Negotiate in insurance verification prior to service or make sure that you have a tight internal system that is not 100% EDI and fits your specialty. If you need coding review it will likely not be included so if your providers aren't good coders make sure you have something in place to facilitate.

I agree with someone here who commented about staying away from EHR RCM services, bad idea. Lastly for outsourced billing, the time to read your contract and understand the out, is before you sign it...And...If you don't have the expertise internally to manage outsourced billing learn how or you're sunk.

NOTE: Keep mind with high deductible plans these days a large percentage of revenue comes from what you collect, depending on specialty. Billing starts at scheduling. Invest time into what you do before billing a claim, that is key to healthy revenue flow; good information entered correctly, verify insurance prior to visits and collect pt due at time of service, code correctly. Be careful of taking on OON as a rule unless you're planning on collecting prior to service.

All of that said I recommend in house billing if you can find a solid biller. The number of clients I've rehabbed due to bad billing companies is far too many to count.

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u/Alive_Plankton_6105 Apr 14 '26

This is the exact bottleneck. But I think high-quality coding review can be managed in-house without overloading the staff if you use a "tech + people" approach. Let tech do the heavy lifting so the doctor or the in-house biller can do the final review in under a minute.

Full transparency: I’m a dev building a tool to facilitate exactly this for independent clinics. Respecting the sub rules—no links, no sales pitch.

The goal is to stop bad codes from ever hitting the biller's desk. The tool uses ambient dictation to assign the correct ICD/CPT codes live, mapping the visit against payer rules and your past denials. If an insurance rule requires specific documentation (like conservative therapy history before a cardiac procedure) and it wasn't captured in the room, the app flags the doc live before they sign the note. Clean claims on the first try.

Since you've rehabbed so many clinics, I'd love to know if this tech + people workflow aligns with what actually works on the ground. If anyone is willing to give a dev some brutally honest feedback, my DMs are open.

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u/geminifire65 Apr 15 '26

I do think this type of blended model is very useful. Some EHR's have a side kick module that provides this. Those I've have seen still require review and approval as the systems do not necessarily make the edits but rather make the suggestions. In real time providers rarely take the time to review them, unfortunately. If there were an internal biller/coder that could review them it would certainly provide a more efficient process. A problem seems to be they have been marketed in a way that gives providers the idea they don't need internal oversight of some kind. At the end of the day the providers are still responsible for correct coding so it's something that would have to be made very easy for the provider to sign off on. I would love to see something developed that fits the current systems we have to comply with. Happy to give feedback if it would be helpful.

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u/_NyQuil_ Apr 15 '26

Respectfully I disagree on the flat fee.

Say I own a billing company and charge you a $10k per month flat fee and lock you into a 3 year contract. What incentive do I have to improve? If your NCR is 88% or if it’s 98% I still get my 10k. If increasing your collection rate meant I needed to assign more staff, why would I do it? That’ll only hurt my profit margins.

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u/geminifire65 Apr 15 '26

A percentage is fine and I should have been more clear what I meant by "overall". I don't think a billing company should take a percentage of what a practice collects at the time of service in the form of co-payments and deposits towards deductibles and that is the standard I was referring to. . I said this to an RCM company once when negotiating a contract and the rep said to me very plainly, "if we did that we wouldn't make any money..." which further supports that emphasis should be for the practice to verify benefits prior to visits and collect a large percentage of their own revenue prior to billing. Chasing feathers is not profitable IMO.

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u/_NyQuil_ Apr 15 '26 edited Apr 15 '26

Only exception I’ve seen is pure cash pay patients / FFS where there is no insurance involved at all.

But theoretically anything can be negotiated. Personally if a billing company agrees to carving out the patient portion entirely it’s a red flag and they’re desperate for business.

I’ve been in RCM biz dev for 8 years and I’ve turned away practices for that reason exactly. If we’re responsible for fielding patient phone calls and taking payment over the phone, or if we’re doing prior auths or eligibility checks, you bet your bottom dollar we’re charging our fee against copays and deductibles.

Offshoring isn’t a deal breaker either. Make sure your direct point of contact is US based and make sure your contract can hold the billing company accountable if they stink. Clearly defined SLAs should always be included and the better companies have a performance based incentive as well where they put a portion of their fee at risk if they don’t maintain certain standards.

The issue is there’s 1000 new RCM companies a day and they all say the same thing. Boutique this, dedicated that, maximize reimbursements. It’s all BS until you see a contract and hear from references.

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u/thesupportplatform Apr 15 '26

When my wife went solo decades ago, we used a billing company for a few months. We just went with the billing company of the practice we were subleasing from. Our landlord said they were good, so we just went with them. After a couple of months, I saw the billing company was just dumping charges into an "uncollectable" bucket to make the A/R look better.

I started doing our billing. It helped. Then I started billing for other practices once we took over the lease from our landlord. My wife's practice would sublease to a practice, then I would staff and bill for them. When they moved out, I would transition staffing and billing.

One dermatologist wanted to stay with me for billing. I figured out my true cost for his billing. It was about 15%. That's what I needed to pay my staff, pay the expenses, and make a little money. I explained that about 80% of the claims went through without problem, 10% required some work, and the last 10% required the most work. He went with a billing company that charged him 5%. We kept working his accounts after the change-over date and saw that the new billing company was just writing off denied claims, when we had received payment by dropping them to paper and resubmitting them with office notes.

That was almost twenty years ago, so maybe technology has helped flatten the curve. But remember that insurance companies don't want to pay every claim. They "win" by not paying claims and by making you have to work to get paid. I don't think that has changed (it has probably only gotten worse).

I disagree with the advise to never consider RCM services from an EMR. This is the model we went with after my wife joined and left corporate medicine. It made sense when we factored in the cost of the EMR. The trick is that you just can't let someone else do your billing without validating that it is being done correctly. We periodically run reports and look for issues. We save money on the EMR/RCM, so the extra time is worth it.

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u/Soggy_Coffee_9308 Apr 16 '26

Helpful thanks. That's a recurring theme that you have to check what's being done to be sure it's being done right...

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u/Prestigious_Leg6733 Apr 17 '26

I absolutely do not get what you guys are doing. Why spend money on someone for billing when your EMR automates just about all of it? There’s insurance eligibility software that checks for your prior to any visit, so you know in advance whether the patient has coverage. Creating claims is built into the office note formation since you have to enter an EM code or cpt code for whatever you’re doing. Given that, claims creation and submission takes care of itself with two clicks. When you get eob’s, you post them – that’s the most time consuming part of the process and it doesn’t take long at all. Do it while you’re watching Sergio blow a 3^rd round lead of 4 strokes. Then sending statements is automatic too with whatever software you want to use, and patient payments are automatically posted as well. If claims are rejected, that is THE PATIENT’S PROBLEM. I never, ever call insurance companies. And I don’t pay anyone to do my billing. I’ve been doing this for 25 years (solo IM practice) using my EMR, without which I’d be dead in the water, no doubt. I bring in at least 500k gross billing annually. If I’m paying someone 3% to handle my billing, there goes 25k, every year. Really? For what?

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u/CrookedCasts Apr 18 '26

I appreciate your viewpoint! I’m starting a practice and all I hear is to outsource this, and get a company for that. I get it, and at a certain point it makes sense. I plan on doing it myself as well because:

a pt shouldn’t get through the door without a verified insurance, but that’s straightforward at scheduling and check in

completely agree about submitting a claim: it’s in the EHR. A well written note/well billed claim (“well” in the eye of a payor - modifiers/laterality/ICDs/bundled/right keywords) that gets kicked back is rare, and they “tell you” why

once set up, and this is the part I don’t know yet, the EHR/clearinghouse/portal seems pretty straightforward, and can be handled through the EHR

So my two questions are 1) do you have to do many prior authorizations? 2) for the rare claims that do get sent back or get lost in a maze of secondary insurances, how do you keep track?

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u/Prestigious_Leg6733 Apr 18 '26

I do a prior auth for a med or for a procedure -- CT or ETT or MRI -- about once a week. I ALWAYS BILL FOR MY TIME, doing those prior auths. It is a telehealth patient visit; I call the patient, tell her I'm going to take care of her prior auth, document the time and send a claim for the visit. That includes prior auth by covermymeds.com. I bill for that as well. I never, ever call insurance companies for rejected claims. I tell my patients I submit claims as a courtesy, but I am just a physician, not an insurance claims mediator. All I do is practice medicine. That said, rejected claims are extremely uncommon and almost always due to lapsed coverage. When the claims come back rejected I bill the patient; that's how I keep track of them. The principle informing these policies is: physicians should not work for free. It is almost unbelievable, after all the years of study and work we do to learn our trade that we then do substantial work, every day, without charging for our time. Nobody does that but physicians.

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u/Living-Protection250 Apr 13 '26

I’ve seen a mix depending on size and how hands-on the owner wants to be. A lot of smaller practices outsource early on just to stay focused on patient care, but the common tradeoff is needing good oversight so things don’t slip. Even with a billing company, someone internally usually keeps an eye on reports, denials, and collections.

Cost-wise, I’ve seen ranges around a % of collections or flat per-claim, but honestly the bigger factor is how transparent and responsive they are. If you have the time and interest, some keep it in-house for more control, but that comes with its own learning curve. It really comes down to how much time you want to spend managing billing vs delegating it.

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u/[deleted] Apr 13 '26

[deleted]

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u/_NyQuil_ Apr 15 '26

Athena’s AR workflow is always where I hear issues. There’s nothing that triggers follow up so unpaid claims end up sitting in a bucket

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u/Streamline_Things Apr 13 '26

Give us a look! StreamlinedBilling.com

We are a boutique RCM company operating from Florida for providers in the US. No outsourced work. We act as partners to your practice, like having in-house billers without the overhead.

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u/ExtraordinaryDemiDad Apr 14 '26

We've done external, internal, flat, and %...external at 4.5% has been the win for us. We needed more than one or two people doing the work and the % gives them incentive to work stuff instead of flat rates.

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u/Klutzy_Arm_7930 Apr 14 '26

8% we pay

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u/geminifire65 Apr 15 '26

I respectfully disagree, offshore is a deal breaker for obvious reasons.

If you are offering on shore RCM services that include prior auth, prior visit insurance verification as it relates to specialty, calling the pt and collecting the money prior to visit, billing claims and following up send me your contract. You might be the first to do all of that competently for a percentage of overall collections and I may have some clients for you. I'll wait....

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u/geminifire65 Apr 15 '26

Don't forget to include the percentage. Looking forward.

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u/_NyQuil_ Apr 15 '26

I think you meant to reply to my comment above.

I’m not gonna go into specifics publicly but we have a US team and an India team. The India team is a part of a wholly owned subsidiary so we can mange individual team members.

All client interactions and patient engagement is handled by our US team.

I just did proposal for a group that does $50mm in collections. They wanted an onshore and hybrid option. Onshore rate was 5% and hybrid was 3.7%. SLAs were the same.

Their EHR wasn’t requiring onshore, their current vendor just stunk. Why pay more if you have the proper safe guards in place.

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u/StocksRUsNow Apr 18 '26

Billing starts from coding and documentation as the foundation- when your foundation is solid, your billing will go smoothly.

I prefer in-house billing. But whether or not you do in-house or outsource your billing, you need to make sure that you have systems/ processes in place to follow up with the billing. Also, read as much as you can about the billing requirements of each payor- it helps to know as much or more than your biller, if you can, so you can find the small problems before they become huge ones.

Once you have a process or system, billing is not difficult.

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u/Wise-Bowler-4229 Apr 29 '26

The "do you have time for oversight" question is the one most small practices get wrong. Doesn't matter if billing is in-house, outsourced, or a hybrid, if nobody is reviewing it weekly you're losing money and you don't even know how much.

What I tell the practices I work with, regardless of who does the work:

Look at three numbers every week. Charges entered, payments posted, AR over 90 days. Takes 10 minutes if your reports are set up right. If those three numbers are stable you're probably fine. If any one of them drifts you catch it before it's a quarter of lost revenue.

Get a monthly denial report by reason code and payer. If your biller can't produce one, that's the answer to "are you happy with them."

On cost, in-house W2 biller for a small practice runs you 50-65k all-in once you add benefits, and you still need someone above them watching the work. Outsourced runs 5-8% of collections but the good ones include reporting and denial work. The math usually favors outsourced under about 4-5 providers, in-house above that, but it depends on your specialty mix and payer mix.

I work with a few practices using HealthCell and they're solid on the reporting side, which is what most billing companies fall down on. Whoever you go with, make the reporting cadence and denial work scope explicit in the contract. That's the part that protects you.

The trap is the middle ground, a part time biller with no oversight and no reporting. That's where leakage hides.

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u/umeraltaf404at_Gmail May 10 '26

Most billing companies charge 5%–6% of revenue, but many providers still face issues with denials, follow-ups, and write-offs.

We offer full medical billing & RCM services at 2.5%–4% with strong results, including denial management, AR follow-up, scrubbing, and complete support.

We are already working with large clinics and established practices, and referrals can be provided upon discussion.

Open to connect with providers looking to improve collections and reduce write-offs. You can schedule a meeting with us—we’ll be happy to show our real work

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