How to choose a medical billing company

Know what you’re hiring a billing company to do

Before you talk to a single vendor, write down what you want off your plate. Some practices want everything from charge entry to patient statements. Others want only denials and aged A/R worked while their in-house biller keeps submitting claims. Some need credentialing and enrollment as well.

That list matters because vendors quote very differently depending on scope, and two proposals that look alike on price can cover very different amounts of work. If you’re still deciding whether to outsource at all, our comparison of in-house vs outsourced billing covers that decision first.

Who will actually work your account

The people on the sales call are rarely the people who work your claims. Ask who will, and ask to speak with them before you sign.

• A named account lead. You want one person who knows your practice, your payers and your providers, and who answers when you call. A shared inbox and a ticket number is a different service.
• The team behind them. Ask how many accounts each biller carries and who covers when someone is out. Billing work that stops for a week shows up in your aging report a month later.
• Where the work is done. Many billing companies use teams outside the US. That can work well, but you should know it up front and understand how your data is protected. Ask where the team is based and how your data is accessed from there.

Certifications and specialty experience

Ask whether the coders hold current credentials, such as the AAPC’s CPC or AHIMA’s CCS, and whether the company audits its own coding on a schedule. Certification doesn’t guarantee good work, but a company that doesn’t require it is telling you something about its standards.

Specialty experience matters more than most practices expect. Cardiology, physical therapy, behavioral health and anesthesia each have billing rules that a generalist team learns slowly, and at your expense. Ask how many practices in your specialty they currently bill for, and ask for a reference from one of them. Then call the reference.

Denial turnaround and reporting

A vendor makes most of its money on clean claims that pay the first time. Denials are where the effort is, and they’re where weak vendors fall behind. Ask directly:

• How quickly is a denial worked after the remittance arrives? Get a number in days.
• Who decides what gets appealed and what gets written off? Write-offs above a set amount should need your approval.
• Do they track denials by root cause and tell you when the cause is on your side, such as front-desk registration errors or missing documentation?

Then ask to see a sample report. At a minimum you should get A/R aging by bucket and payer, denials by reason and payer, collections against charges, and a list of open issues with owners. A month-end PDF of totals isn’t enough to manage a practice with. Our claims and denial management page shows how we approach this work.

Data ownership, contract length and exit terms

The time to negotiate your exit is before you sign. Read the contract for these:

• Who owns the data. Your claims, payment history and patient balances belong to your practice. The contract should say so and give you a full export, in a usable format, at any time and at no charge.
• Which system holds it. If the vendor bills out of its own practice management system, find out what you get back when you leave. A pile of PDFs isn’t a usable export.
• Term and notice. Look at the initial term, the auto-renewal clause and the notice period. Long lock-ins mainly protect the vendor.
• The run-out. When you leave, who works the claims already in process? Agree in writing how the tail of your A/R is handled and how it’s billed.
• Termination fees. Some contracts charge to leave. Know the number before it matters.

HIPAA, the BAA and your EHR

A billing company handles protected health information on your behalf, so it’s your business associate under HIPAA. You need a signed Business Associate Agreement before any patient data moves. Ask for their BAA early, read it, and ask how they handle access control, audit logs, staff training and breach notification.

Then ask how they’ll work with your EHR or practice management system. Some vendors work inside your system with their own logins. Others need to move you onto their software. Working in your system is usually less disruptive and keeps your data where you can see it. Either way, ask who controls user access and how quickly it’s removed when someone leaves their team.

Pricing models and what’s actually included

Medical billing pricing generally falls into a few models:

• Percentage of collections. The most common. It ties the vendor’s income to yours, but confirm whether the percentage applies to all collections or only to what they collected, and whether patient payments count.
• Per-claim fees. Predictable, but they reward volume over results, and denied claims can be charged twice.
• Flat monthly fees. Simple to budget. Check what happens when your volume changes.

The fee is only half of it. Ask what’s included and what costs extra: clearinghouse fees, patient statements and postage, credentialing, coding audits, old A/R cleanup from before the start date, and software licenses. A lower headline rate with five add-ons can cost more than a higher rate that covers everything.

Red flags when choosing a medical billing company

• They promise a specific collection increase before looking at your data.
• They can’t tell you who will work your account.
• The sample report is a single page of totals.
• They won’t put data ownership and export rights in the contract.
• They’re vague about where their team works or how your data is protected.

You can see how we answer these questions on our why choose us section.

If you want an independent read on where your revenue stands before you choose anyone, ask for a free A/R audit. We’ll analyze your recent claims by payer, provider and denial reason, and you keep the findings either way.