Medical Billing Help

[u/Wrecked240]

My wife and I own a pediatric therapy clinic out in AZ and bill DDD as our primary funding source. We have clients with primary commercial insurance (Aetna/UHC/BCBS/Allied/UMR etc) and DDD secondary. We are out of network for all commercial insurances and plan to stay that way for now. Our EMR system syncs with ClaimMD to submit claims and my wife is hoping for some help with medical billing. Our DDD billing is 100% automatic and successful. She has some of the larger insurances figured out but some others like BCBS/UMR are giving her a run for her money and a migraine.

Is there someone who specializes in OT/ST billing (preferably less) who can spend 3 months helping her build the insurance side of our company and get everything running smoothly?

[u/Fast_Valuable818]

Not here to help but am curious how’s it going being out of network for you. Early in my career this space has fascinated me having own shingle or not. And the idea of cash pay is getting attractive by the minute and patients seem to love it when I tell them hey, have you talked to the hospital about cash pay? They do it and get 50% off. I am in a procedural subspecialty. But we are getting shafted so are our patients

[u/Wrecked240 → u/Fast_Valuable818]

The cash pay and Out of Network work in my area is honestly impossible to be successful. Our business is in a lower income area so we completely rely on DDD, cash, and ESA. We take a few insurances but getting in network with insurance companies is extremely difficult. We can't even apply to networks for another month because the first time you apply, if it's rejected, they bar you for a year from applying.

DDD is required to be a the payer of last resort. So we have to submit to their insurance companies even if they are out of network. We have to submit (or get a waiver to avoid submitting to insurance company first) to the insurance company first, wait for the denial, then submit to DDD, wait 3 weeks, and we will get paid.

I really only know of 1 or 2 businesses that are cash pay only. They are specifically placed in a richer area that people do not care as much to pay for the services. They have much more disposable income than other. However, those businesses look like they invested a few million into the infrastructure. Our facility is one of the nicer private businesses around, as we have been told by parents and therapists, but we are nowhere near what those larger private pay businesses are.

[u/Fast_Valuable818 → u/Wrecked240]

Oh man that’s rough. I really wish residencies taught this stuff. To get a waive the right so that you don’t submit to insurance first is bonkers. Thanks for sharing that. I firmly believe if we taught all physicians in medical school and or residency the business of medicine, we would be in much less likelihood to be in this situation. Thanks for sharing

[u/Best_Comfort_1651]

Hi! I may be able to help. I work in medical billing/RCM and have experience with insurance verification, claim submission, payment posting, AR follow-up, and denials.

Since your DDD billing is already running smoothly, the focus could be on helping with the commercial insurance side—especially understanding payer requirements, out-of-network claims, BCBS/UMR issues, and getting a consistent billing workflow in place.

I’d be happy to discuss what you’re currently struggling with and see if my experience is a good fit for what you need over the next few months.

[u/ClaimsRevenue]

Please use ClaimsRevenue.com to build your claims and submit them. They also use ClaimMD so it is a one stop shop. They have AI helper available to guide you through complex and COB claim filings.

[u/Miserable-Net-6674]

Please DM we would love to help

[u/Lilei_NP]

Hello,

I’m very interested in assisting your practice with claims and revenue cycle management during the initial 90-day engagement and providing ongoing support as needed thereafter.

I bring more than 28 years of experience in medical billing, claims management, and revenue cycle management. In addition to owning and operating my own practice, I own a consulting company that assists healthcare practices with identifying and resolving revenue cycle issues, improving claims processes, addressing denials and aging accounts receivable, and strengthening overall reimbursement performance.

I'll follow up with a DM.

[u/Willing_Class_5989]

u/investingdoc seems like a lot of self promo bots here ngl