Eligibility, benefits, and prior authorization before the visit
Verified before the visit — not after the denial. Coverage confirmed, authorizations submitted per payer on schedule.
Physician billing services
Physician billing services for practices that bill on the CMS-1500
Physician billing is professional billing: the CMS-1500 side of the revenue cycle. A claim is paid on the code, the modifier, and the documentation behind it. We run that side for practices in all 50 states, from charge capture through denial resolution. We report our clean claim rate at the payer.
97% first-pass at the payer | 14-day onboarding | $0 setup | 50 states
97% clean claim rate — measured at the payer
14-day onboarding
No setup fees
All 50 states
Understanding the difference
Professional billing is not facility billing
A physician bills for the work of the provider. A hospital bills for the building. The claims travel on different forms, price on different systems, and get denied for different reasons. Treat them the same and you lose on both.
| Physician (professional) | Facility | |
|---|---|---|
| Claim form | CMS-1500 / 837-P | UB-04 / 837-I |
| Priced on | RVUs under the fee schedule | DRG or APC |
| Coding | CPT, ICD-10-CM, HCPCS, modifiers | ICD-10-PCS, revenue codes |
| Denied most for | E/M level, modifiers, medical necessity, prior auth | DRG, patient status, authorization |
If your practice also carries a facility component, our hospital billing team runs that side. This page is about the professional claim.
Where physician revenue slips
Where physician revenue slips
Payers denied 11.8% of claims on first submission in 2024. For Medicare Advantage, the initial rate reached 23.35%, nearly one in four. Most are paid in the end, but only after staff time to rework them and a delay in the cash. That delay is the cost.
Prior authorization carries the heaviest load. Physicians average 40 requests a week and 13 hours of staff time. About one in three say those requests are often or always denied.
23.35%
Initial denial for Medicare Advantage — nearly 1 in 4
By the numbers: 11.8% initial denial across all payers, 23.35% for Medicare Advantage, and 40 prior authorizations a week at 13 hours of staff time.
Two places leak the most: the claim that goes out coded a level too low, and the authorization nobody chased before the visit. Our physician medical billing services close both.
What we manage
What we run across the physician revenue cycle
Our physician billing services cover the professional revenue cycle end to end. This is physician revenue cycle management run as one connected process, so a denial pattern changes how the next claim is coded.
Specialty-assigned CPT, ICD-10, and E/M coding with charge capture
Charge capture assigned by specialty at onboarding — coding worked by people who know that specialty's edits. See also: medical coding services.
Claim scrubbing against payer rules and NCCI edits
Every claim checked against payer-specific rules and NCCI edit sets before submission. Errors caught before they become denials.
Payment posting and denial resolution by root cause
Denials worked by root cause, not batch-processed by age. Patterns feed back into coding so the same mistake does not recur.
Accounts receivable follow-up and patient statements
AR worked by payer-specific escalation paths. Patient statements generated and followed up so aging does not accumulate.
Provider credentialing and payer enrollment kept current
NPI, CAQH, PECOS, and payer applications managed with re-credentialing dates tracked. A lapsed enrollment stops payment — we prevent that.
Coding is assigned by specialty at onboarding, so a cardiology or dermatology claim is worked by someone who knows that specialty's edits, not a general queue.
The quietest revenue loss
E/M level optimization, the quietest revenue loss
The most common way a physician claim loses money is not a denial. It is a visit billed one level below what the record supports. That is under-coding, and it is silent.
Under the 2021 guidelines, an office visit is coded by medical decision making or total time, not by how much was typed. A 99214 pays about $40 more than a 99213 under the 2026 Medicare Physician Fee Schedule, roughly $135 against $95 in the office. Commercial payers pay 120 to 200 percent of that. Picture one provider seeing 90 established patients a week. Move ten from a 99213 to the 99214 the note already supports, and that is about $400 a week. Over a year it passes $20,000, from visits that already happened. No denial ever fires.
We review each encounter against the decision-making criteria and code the level the documentation supports, up or down. Where it cannot support a level, the provider gets specific feedback, so the fix lands at the chart. A 99214 is also among the most audited codes. The review that catches under-coding is the one that holds up under an audit.
$20K+
From visits that already happened
Move 10 patients a week from 99213 to the 99214 the note already supports — at ~$40 more per visit. No denial ever fires.
$40More per visit
99213 → 99214
99213 → 99214
$400More per week
10 visits moved
10 visits moved
Denial prevention
Where physician claims get denied, and how we stop it
Physician denials cluster in a handful of codes. We catch each before the claim leaves, not after it comes back. Prevention beats appeals here.
| Denial | How we stop it |
|---|---|
| E/M level mismatch | Decision-making review on every encounter, coded up or down to the record |
| CO-50 medical necessity | ICD-10 checked against the payer's coverage policy before billing |
| CO-97 bundling and modifier 25 | NCCI edits checked; modifier applied only when the service is separate |
| CO-29 timely filing | Submission inside a set turnaround with deadline monitoring |
| Prior-auth denial | Authorization tracked per payer before the service is rendered |
Specialized workflows
Every part of the professional revenue cycle, managed
4 in 5
Prior authorization, handled before the visit
Prior authorization is where a practice loses the most staff time. Physicians average 40 requests a week and 13 hours. Roughly one in three are often or always denied. Left to the front desk, it becomes hold music and missed deadlines. We take it off the front desk.
We submit and track authorizations per payer before the visit, watch the status, and appeal the denials that are wrong. Around four in five appealed prior-auth denials get overturned, so the appeal is usually the right call.
~4 in 5 appealed denials overturned1 fix
Telehealth billing without the repeat errors
Telehealth denials tend to hit every claim at once. They come from a setup error, not a single mistake. Fix the setup once.
Place of service decides it: POS 10 when the patient is at home, POS 02 when they are not. Modifier 95 marks synchronous audio-video, modifier 93 marks audio-only, and the two are not interchangeable. Under parity laws in most states, commercial payers reimburse telehealth at in-person rates, but only when the POS and modifier are right.
We set the place-of-service and modifier pairing per payer and confirm parity rules on commercial claims. The same visit does not get denied twice.
−9%
MIPS reporting, scored honestly
MIPS moves Medicare Part B payments up or down two years later. The performance threshold is 75 points, and the maximum penalty is 9 percent. The upside is smaller than it sounds: the program is budget neutral, so positive adjustments are scaled down and rarely reach the headline figure.
We report Quality, Promoting Interoperability, and Improvement Activities to clear the threshold and avoid the penalty. We tell you the realistic upside, not the statutory maximum.
Max penalty: 9% of Part B$0
Credentialing and enrollment kept current
A lapsed enrollment stops payment with no denial code to warn you. A PECOS deactivation or an expired CAQH attestation quietly holds every Medicare claim for that provider.
Our credentialing team — managed at medical-credentialing services — manages NPI, CAQH, PECOS, and payer applications, and tracks re-credentialing dates so a gap never reaches your remittance.
Zero gaps in enrollmentTwo places leak the most. Let us show you exactly where yours is.
The free assessment pulls a sample of your claims and shows your E/M distribution against benchmark, your top denial reasons by dollar, and your aged AR by payer. You keep the findings.
Honest comparison
In-house or outsourced, the honest version
Outsourcing usually gets weighed as a cost line. For a physician practice, it is closer to a coverage question. A single biller runs about $50,250 a year in salary before benefits, and that one seat carries E/M coding, prior auth, denials, and every CPT change alone. When it sits empty for a quarter, collections stall with it. One seat is one point of failure.
We work on a percentage of what we collect, so we are paid when you are paid. There is no seat to backfill, and no long-term contract if it stops working. If you already run a strong billing team, we take only the piece that is leaking, whether that is AR, denials, or credentialing. That is medical billing for physicians shaped to the practice, not a fixed package.
$50,250
Median biller salary · per year · before benefits (BLS.gov)
- One biller carries E/M coding, prior auth, and denials alone
- When that seat is empty, collections stall with it
- We are paid when you are paid — percentage of collections
- No setup fee. No long-term contract required.
- Take only the leaking piece — AR, denials, or credentialing
Documented client work
What changed for the practices we took on
These are physician practices we bill for now. The charges did not change; the collections did.
18.2% → 61%
Collection rate on identical charges
Six-provider groupPrimary care practice$0 → $43,678
Monthly collections after ERA & EFT enrollments that had never been completed
$178,237Monthly charges, unchanged$60,000
Revenue retained in a one-time audit
Divine DermatologySpecialty dermatology practicePatient First, a six-provider primary care group, moved from an 18.2% to a 61% collection rate. Psychiatric Connections, a behavioral health practice, went from $0 to $43,678 a month once we set up the ERA and EFT enrollments that had never been completed. A one-time audit retained $60,000 for Divine Dermatology. The full case studies are here.
How we measure it
The 97% we report, and where we count it
97%
First-pass clean claim rate
As a physician billing company, our 97% first-pass rate is measured at the payer on professional (837-P) claims. It is not the clearinghouse figure, which always reads higher. Every account runs inside our Revenue Control Framework — the five-phase method behind each engagement — and there is no setup fee or long-term contract. About the framework →
837-P professional claims only
Not clearinghouse acceptance — that figure reads 7–12 points higher
First submission · zero rework
A claim that needed a correction before it paid does not count
Measured at the payer
Where it matters — not where it looks best on a dashboard
No setup fee · no contract
No long-term commitment required to start
System compatibility
The systems we already work inside
Switching billing usually raises the fear of ripping out your systems. You keep them. We work inside your existing setup, including Epic, Athenahealth, eClinicalWorks, NextGen, Kareo, and AdvancedMD, among others, with integrations scoped during the revenue assessment.
EpicAthenahealtheClinicalWorksNextGenKareoAdvancedMDOffice AllyPractice FusionDrChronoGreenway Health
No forced platform migration. Custom integrations scoped at no extra charge.
Fit check
Who this is for
We are a strong fit for some practices and the wrong choice for others. We would rather say so up front.
Good fit
- Physician practice billing on the CMS-1500 wanting collections measured at the payer
- Revenue leaking in denials, aged AR, or under-coded E/M levels
- A specialist team that knows your payers, not a rules engine
- Practices in any specialty across all 50 states
- Practices wanting to keep their EHR and hand off the billing layer
Probably not a fit
- You want the lowest possible percentage and nothing else
- You want to keep billing fully in-house and only need software
Common questions
Physician billing questions we get asked
Direct answers for physician practices evaluating an outside billing partner.
What is the difference between physician billing and hospital billing?
The two get confused constantly, and billing them the same way is where money leaks. Physician, or professional, billing covers the provider's work on the CMS-1500 or 837-P, priced by RVUs under the fee schedule. Hospital, or facility, billing covers the building on the UB-04, priced by DRG or APC. One encounter can generate both, and they are coded and denied differently.
How do you improve E/M coding accuracy?
Most practices lose money to under-coding without ever seeing a denial. We review each encounter against the 2021 decision-making criteria and code the level the documentation supports, up or down. Where the record cannot support a level, the provider gets specific feedback, so the fix happens at the chart, not claim by claim.
Do you handle prior authorization?
Prior authorization is the biggest time sink most practices have, and the easiest to hand off. Yes, we submit and track authorizations per payer before the visit and appeal the denials that are wrong. Most appealed prior-auth denials are overturned, so the appeal is usually worth filing.
Can you bill telehealth correctly across states?
Telehealth denials tend to repeat across every claim, because one setup error hits them all. Yes, we apply the correct place-of-service code and modifier for each payer, then confirm state parity rules, so those claims stop getting rejected.
Do you support MIPS reporting?
The risk with MIPS is a penalty of up to 9 percent, and the upside is usually oversold. Yes, we report the categories that clear the 75-point threshold and keep you off the penalty, and we give you a realistic view of the upside, not the statutory maximum.
What EHR and practice management systems do you work with?
Switching billing usually raises the fear of ripping out your systems. You keep them. We work inside your existing setup, including Epic, Athenahealth, eClinicalWorks, NextGen, Kareo, and AdvancedMD, among others, with integrations scoped during the revenue assessment.
How fast can you onboard, and is there a contract?
The worry is a long, disruptive switch that locks you in. Neither happens here. Onboarding runs about 14 days with no gap in claim submission, no setup fee, and no long-term contract.
How do you measure your clean claim rate?
This is the number to pin any billing company on, because it is easy to inflate. We measure ours at the payer, on first submission, with zero rework, so a claim that needed a correction before it paid does not count. Many vendors quote clearinghouse acceptance instead, which reads higher.
Ready when you are
The free assessment is specific.
We pull a sample of your claims and show your E/M distribution against benchmark, your top denial reasons by dollar, and your aged AR by payer. You keep the findings whether or not you work with us. If you decide to outsource physician billing services after that, onboarding runs about two weeks, with no setup fee and no long-term contract.
- E/M distribution benchmarked against your specialty
- Top denial reasons by dollar from your AR
- Aged AR by payer — filing window exposure
- You keep the findings either way
- HIPAA-compliant — BAA signed before data moves
- No setup fee. No long-term contract.