Outsourcing your billing is one of the more significant operational decisions your healthcare organization can make. When you pick the right company, outsourcing frees up internal resources, tightens revenue cycle performance, and gives your team more bandwidth to focus on patient care. If you get saddled with the wrong partner, it creates more problems than it solves. 

The difference often comes down to how thoroughly you evaluated both your own readiness and the strengths (and weaknesses) of vendors you considered before signing a contract. 

We’ve been handling revenue cycle management for healthcare organizations across the country for over 30 years – these are the top five questions you should be asking every potential outsourcing vendor before you sign on the dotted line. 

1. Are we actually ready to outsource? 

This question gets skipped more often than it should. Outsourcing your billing is not an automatic fix for a disorganized revenue cycle. If your charge capture process has gaps, your documentation is inconsistent, or your payer contracts haven’t been reviewed in years, an external billing team will inherit those problems and if the external team isn’t armed with the experience and bandwidth to build out those new workflows for you (and then provide training and education for your team) it means one of two things: either you’re not ready for outsourcing yet, or they are not the right vendor for you. 

Before evaluating vendors, do an honest internal assessment. How clean is your data? Are your denial rates within normal benchmarks, or are there patterns suggesting deeper workflow issues? 

If you’re not sure where to start, our free resource Are You Ready for Revenue Cycle Management? walks through the key areas to assess before making the transition. 

2. Do they have meaningful experience in your specific setting? 

Healthcare billing is not one-size-fits-all. A billing organization with strong experience in orthopedic group practices may have very little familiarity with community mental health billing. A team that handles hospital outpatient well may not understand the nuances of independent physician practice reimbursement. 

Ask potential billing organizations to be specific about their experience in your care setting, your specialty mix, and your primary payer types. Ask how many current clients they serve in a similar setting. Vague answers to specific questions are worth paying attention to. 

3. Who will you actually be working with, and how often will you hear from them? 

This question reveals more about a billing organization than almost any other. Once a contract is signed, the friendly (and incredibly available) Sales Team disappears, and you’re left with the day-to-day relationships with your new billers. What those look and feel like matter enormously. 

Find out whether you’ll have a dedicated point of contact or whether your questions go to a general support queue. Ask what a typical communication cadence looks like. Will you have regular meetings to review performance and flag concerns? Or will you receive a monthly report and otherwise be left to reach out when something goes wrong? 

The most effective outsourcing relationships tend to feel less like a vendor arrangement and more like an extension of your internal team. A billing organization that proactively communicates and genuinely engages with your mission brings much more value than one that simply processes claims. 

4. How do they handle denials and appeals? 

Denial management is where a lot of billing organizations quietly underperform. Submitting clean claims is the baseline. What separates strong performers from average ones is what happens after a claim is denied. 

Ask vendors to walk you through their denial management workflow. How quickly are denials worked? Do they track denial trends by payer and reason code to identify root causes, or do they just resubmit individual claims? Ask for benchmarks from their current client base and how their performance compares to industry standards. 

5. What does the contract actually say? 

It’s easy to focus on the pitch and give less attention to the contract itself, but reading the fine print is well worth your time. 

Before signing, understand the termination clause. How much notice is required, and what does the data return process look like if you decide to leave? Look for performance guarantees, and if they are included in the contract, make sure you understand how disputes are handled if their performance falls short. 

Contracts that are easy to exit (with reasonable notice and a clean data handoff) typically signal a vendor confident in their ability to retain clients through performance rather than obligation. 

Bonus: Additional Questions for FQHCs 

If you are a Federally Qualified Health Center, there are a few additional questions specific to your billing environment worth asking directly. 

Do they have verified experience billing under the Prospective Payment System? 

PPS billing is meaningfully different from fee-for-service. Encounter qualification rules, same-day visit protocols, and UDS reporting requirements all require specific familiarity. Ask how many FQHC clients they currently serve and whether they have staff dedicated to health center billing specifically. 

How do they handle Medicaid managed care wraparound reconciliation? 

Wraparound payments are a significant revenue stream for most FQHCs and require systematic tracking and timely submission. Ask what their reconciliation process looks like, how frequently they submit, and whether they’ve identified missed wraparound payments for clients they’ve onboarded. 

Are they familiar with HRSA compliance requirements as they relate to billing? 

Billing and HRSA compliance intersect more than many health centers realize, particularly around credentialing, privileging, and encounter documentation. A billing organization that understands your federal designation requirements can flag compliance-adjacent issues before they become problems, not after. 

Outsourcing your billing is a significant decision, and the right fit looks different for every organization. Taking time to ask the right questions before you commit is the most reliable way to make sure the relationship you enter actually serves your team, your patients, and your mission. 

If you’d like to talk through where your organization stands, we’d love to connect! 

Tag: denial management

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Title

As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
Continue Readiing
image

Title

As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
Continue Readiing

Five Questions to Ask Before You Outsource Your Billing 

Posted on by Carolyn Yoder

Outsourcing your billing is one of the more significant operational decisions your healthcare organization can make. When you pick the right company, outsourcing frees up internal resources, tightens revenue cycle performance, and gives your team more bandwidth to focus on patient care. If you get saddled with the wrong partner, it creates more problems than it solves. 

The difference often comes down to how thoroughly you evaluated both your own readiness and the strengths (and weaknesses) of vendors you considered before signing a contract. 

We’ve been handling revenue cycle management for healthcare organizations across the country for over 30 years – these are the top five questions you should be asking every potential outsourcing vendor before you sign on the dotted line. 

1. Are we actually ready to outsource? 

This question gets skipped more often than it should. Outsourcing your billing is not an automatic fix for a disorganized revenue cycle. If your charge capture process has gaps, your documentation is inconsistent, or your payer contracts haven’t been reviewed in years, an external billing team will inherit those problems and if the external team isn’t armed with the experience and bandwidth to build out those new workflows for you (and then provide training and education for your team) it means one of two things: either you’re not ready for outsourcing yet, or they are not the right vendor for you. 

Before evaluating vendors, do an honest internal assessment. How clean is your data? Are your denial rates within normal benchmarks, or are there patterns suggesting deeper workflow issues? 

If you’re not sure where to start, our free resource Are You Ready for Revenue Cycle Management? walks through the key areas to assess before making the transition. 

2. Do they have meaningful experience in your specific setting? 

Healthcare billing is not one-size-fits-all. A billing organization with strong experience in orthopedic group practices may have very little familiarity with community mental health billing. A team that handles hospital outpatient well may not understand the nuances of independent physician practice reimbursement. 

Ask potential billing organizations to be specific about their experience in your care setting, your specialty mix, and your primary payer types. Ask how many current clients they serve in a similar setting. Vague answers to specific questions are worth paying attention to. 

3. Who will you actually be working with, and how often will you hear from them? 

This question reveals more about a billing organization than almost any other. Once a contract is signed, the friendly (and incredibly available) Sales Team disappears, and you’re left with the day-to-day relationships with your new billers. What those look and feel like matter enormously. 

Find out whether you’ll have a dedicated point of contact or whether your questions go to a general support queue. Ask what a typical communication cadence looks like. Will you have regular meetings to review performance and flag concerns? Or will you receive a monthly report and otherwise be left to reach out when something goes wrong? 

The most effective outsourcing relationships tend to feel less like a vendor arrangement and more like an extension of your internal team. A billing organization that proactively communicates and genuinely engages with your mission brings much more value than one that simply processes claims. 

4. How do they handle denials and appeals? 

Denial management is where a lot of billing organizations quietly underperform. Submitting clean claims is the baseline. What separates strong performers from average ones is what happens after a claim is denied. 

Ask vendors to walk you through their denial management workflow. How quickly are denials worked? Do they track denial trends by payer and reason code to identify root causes, or do they just resubmit individual claims? Ask for benchmarks from their current client base and how their performance compares to industry standards. 

5. What does the contract actually say? 

It’s easy to focus on the pitch and give less attention to the contract itself, but reading the fine print is well worth your time. 

Before signing, understand the termination clause. How much notice is required, and what does the data return process look like if you decide to leave? Look for performance guarantees, and if they are included in the contract, make sure you understand how disputes are handled if their performance falls short. 

Contracts that are easy to exit (with reasonable notice and a clean data handoff) typically signal a vendor confident in their ability to retain clients through performance rather than obligation. 

Bonus: Additional Questions for FQHCs 

If you are a Federally Qualified Health Center, there are a few additional questions specific to your billing environment worth asking directly. 

Do they have verified experience billing under the Prospective Payment System? 

PPS billing is meaningfully different from fee-for-service. Encounter qualification rules, same-day visit protocols, and UDS reporting requirements all require specific familiarity. Ask how many FQHC clients they currently serve and whether they have staff dedicated to health center billing specifically. 

How do they handle Medicaid managed care wraparound reconciliation? 

Wraparound payments are a significant revenue stream for most FQHCs and require systematic tracking and timely submission. Ask what their reconciliation process looks like, how frequently they submit, and whether they’ve identified missed wraparound payments for clients they’ve onboarded. 

Are they familiar with HRSA compliance requirements as they relate to billing? 

Billing and HRSA compliance intersect more than many health centers realize, particularly around credentialing, privileging, and encounter documentation. A billing organization that understands your federal designation requirements can flag compliance-adjacent issues before they become problems, not after. 

Outsourcing your billing is a significant decision, and the right fit looks different for every organization. Taking time to ask the right questions before you commit is the most reliable way to make sure the relationship you enter actually serves your team, your patients, and your mission. 

If you’d like to talk through where your organization stands, we’d love to connect! 

image

Title

As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
Continue Readiing
image

Title

As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
Continue Readiing

Your Revenue Cycle Doesn’t Need an Overhaul (It Needs This Instead) 

Posted on by Carolyn Yoder

When healthcare leaders think about improving their revenue cycle, there’s a natural tendency to think big: new software platforms or entirely new teams. The assumption is often that fixing large revenue cycle problems requires equally large and dramatic solutions. 

Here’s what we’ve learned after decades of working with healthcare organizations nationwide: the biggest financial gains often come from small, targeted adjustments. 

The Problem with “Rip and Replace” 

Major overhauls sound transformative, but they come with real costs: months-long implementation timelines, extensive staff retraining, and disrupted daily operations. There’s no guarantee a new system will solve your specific problems better than fixing systems you already have in place. 

According to the American Medical Association, even small improvements in revenue cycle management can strengthen cash flow. Organizations don’t need to chase every metric at once. Success comes from picking one or two key performance indicators, tracking them consistently, and using focused attention to move the needle. 

Where Small Changes Create Big Impact 

Front-End Accuracy 

The most expensive billing problems are often the ones that start at registration. A missing insurance number, an incorrect date of birth, or an unverified coverage detail creates a domino effect that touches every step that follows. 

Small adjustment: Implement a simple verification checklist at check-in. Train front desk staff to capture three critical data points correctly every single time. This 10-minute workflow change can reduce your denial rate significantly. 

Claim Scrubbing Before Submission 

Most organizations submit claims and deal with errors only after they’re denied. This creates unnecessary delays and rework for both billing and clinical teams. 

Small adjustment: Add a review step between coding and submission. A structured billing assessment can identify which claim types are most likely to have errors, letting you focus quality checks on high-risk categories rather than manually reviewing everything. 

Days in Accounts Receivable 

Anything between 30 and 45 days in AR means claims are moving and reimbursement is timely. More than 90 days is a red flag. Yet many organizations only look at this number quarterly, and by then the damage is already done. 

Small adjustment: Schedule weekly 15-minute check-ins focused solely on AR aging. When your leadership understands what those numbers mean, they start asking better questions and connecting daily operations with financial outcomes. 

Denial Pattern Recognition 

Most billing teams address denials reactively, one claim at a time. This keeps them busy but doesn’t stop the same problems from recurring. 

Small adjustment: Spend one hour monthly reviewing denial reasons by category. If you’re seeing repeated denials for the same service or payer, that’s a signal that something upstream needs attention. One coding audit focused on your highest-denial CPT codes can reveal patterns you’d never catch just by handling individual claims. 

Special Considerations for FQHCs 

Community health centers face unique revenue cycle complexity that makes small adjustments even more valuable. FQHCs billing includes the Prospective Payment System, where they receive a fixed encounter rate rather than fee-for-service payments. This means every missed or incorrectly documented encounter represents lost revenue that can’t be recovered by simply resubmitting a claim. 

Small adjustments that create outsized impact for FQHCs: 

Encounter Documentation Training: A brief monthly training on what qualifies as a PPS-eligible encounter helps clinical staff self-monitor their documentation. When providers understand that a face-to-face visit must include specific elements, accuracy improves without adding administrative burden. 

Sliding Fee Scale Verification: Income verification delays slow down billing and create compliance risks. Establishing a clear timeline for when verification must be completed, and who’s responsible for follow-up, helps eliminate this common bottleneck. 

State-Specific PPS Rules: Medicaid PPS methodologies vary by state. Understanding whether your state allows Alternative Payment Methodologies can open up flexibility you didn’t know existed. A simple review of current state regulations might reveal opportunities for rate adjustments based on scope of service changes. 

Why This Approach Works 

Small adjustments succeed because they’re specific (addressing one identified problem), measurable (you see results in weeks, not months), sustainable (staff can absorb gradual changes without overwhelm), and cost-effective (optimizing what you have rather than buying something new). Small wins build confidence and reduce resistance to future improvements. 

Getting Started 

The challenge isn’t usually knowing that improvements are needed. Most healthcare leaders can name three revenue cycle problems off the top of their head. The real question is knowing where to start and what will make the biggest difference for your specific situation. 

This is where a focused assessment provides clarity. A billing department review or coding audit doesn’t need to examine every aspect of your operation. It can zero in on your highest-impact opportunities and show you the specific adjustments that will move your organization’s unique metrics. Understanding where you are today makes it possible to choose one high-value change, implement it well, and build from there. 

Small changes, applied consistently to the right problems, create compound results that major overhauls rarely deliver. Sometimes the smartest investment isn’t the biggest one. It’s the most targeted.