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Medical billing teams often use claim rejection vs claim denial interchangeably, but they are not the same. A rejection generally occurs before a claim has completed payer processing because of missing, invalid, or incorrectly formatted information. A denial usually means the payer processed the claim but determined that it will not be paid as submitted. The correction process is therefore different for each. Knowing the difference matters because sending the wrong response c

A cardiology practice we work with used to lose an average of 11 days between the moment a physician ordered a stress test and the moment the payer actually approved it. Eleven days of a patient waiting, a scheduling slot on hold, and staff time spent chasing a fax that may or may not have gone through. That's what prior authorization healthcare workflows look like when nobody owns the process end to end. Prior authorization isn't just an administrative step. It's one of the

A family medicine practice we worked with hired a new physician in March. She saw her first patients in April. The practice didn't get paid for a single one of those visits until late July, because her credentialing with two major commercial payers still wasn't finished. That's three and a half months of billable work sitting in limbo, not because the care wasn't good, but because the medical credentialing process hadn't caught up to the calendar. This happens more often than

eClinicalWorks is one of the most widely used EMR and practice management platforms in the country, and for good reason. It's flexible, it handles a lot of specialties well, and it gives practices real control over their scheduling, documentation, and billing in one place. But here's what we see over and over when we review a new practice's revenue cycle: the software isn't usually the problem. It's how the billing workflow is set up inside it. We've audited eClinicalWorks bi

Why Psychiatry Medical Billing Trips Up New Practices Psychiatry medical billing has a reputation for being harder than it looks, and there's a real reason for that. It combines two different coding systems, evaluation and management (E/M) codes and psychotherapy codes, and asks you to document time, medical necessity, and treatment complexity all in the same note. We've reviewed intake files from new psychiatry practices where the clinical care was excellent, but the claims

At some point, almost every practice owner asks the same question: should we keep billing in-house, or is it time to outsource medical billing to someone who does this all day, every day? There's no universal right answer. A four-provider dermatology group and a solo family medicine practice don't have the same claim volume, the same payer mix, or the same tolerance for risk. But there is a right answer for your practice, and it comes down to two things: what your current set

Independent healthcare practices continue to face increasing administrative demands, and MIPS Reporting 2026 remains one of the most important Medicare reporting responsibilities. Successfully meeting reporting requirements can help practices earn positive payment adjustments, while poor performance or incomplete reporting may result in Medicare payment penalties. Understanding the reporting process early gives practices more time to improve quality performance, strengthen do

If half of your accounts receivable is sitting past 90 days, you don't have a billing problem. You have a cash flow crisis that hasn't fully hit yet. I've walked into practices where aging AR had climbed past 50%, and the owners assumed that was just how billing worked. It isn't. Healthy practices keep AR over 90 days somewhere under 5-10% of total receivables. The distance between those two numbers is real money - money you've already earned but haven't collected. Here's exa

Cardiology is one of the hardest specialties to bill correctly. Between diagnostic testing, interventional procedures, device management, and evaluation and management visits that often happen on the same day, a single cardiology encounter can generate five or six billable events. Miss one modifier or bundle two codes that shouldn't be bundled, and the whole claim comes back. We've reviewed claims for cardiology groups ranging from solo practitioners to multi-physician cardia

Ask ten people on your staff what "revenue cycle management" means, and you'll probably get ten different answers. Some will say it's just medical billing. Others will point to the claims department. A few will shrug and say "isn't that the insurance stuff?" They're not wrong, exactly. They're just describing one piece of something much bigger. Revenue cycle management, or RCM, is the entire financial journey of a patient encounter from the moment someone books an appointment

Most practices don't lose money on athenahealth because the software is broken. They lose money because of small, repeatable habits that never get corrected, a missing modifier here, a charge that never gets entered there, a denial that sits untouched for six weeks. Add those up over a year, and you're looking at tens of thousands of dollars that never should have left the table. I've reviewed enough revenue cycles to know that athenahealth is a capable platform. It has stron

If your practice uses Tebra, you already have a capable billing platform. Yet many providers experience claim denials, delayed reimbursements, and inconsistent cash flow and assume the software is to blame. In reality, reimbursement issues are usually caused by workflow gaps rather than the platform itself. This article explains how to maximize reimbursements while continuing to use Tebra, without the cost and disruption of switching software. Why Switching Software Usually I

A denied claim doesn't just cost you the reimbursement. It costs you the staff time to figure out why it was denied, the time to correct it, the time to resubmit it, and then the wait for a second decision that might land on you again. Multiply that by even a modest denial rate, and you're looking at one of the biggest silent drains on an independent practice's revenue. Industry surveys put the average initial denial rate somewhere between 10% and 15% of submitted claims, and

As a healthcare provider, BillingTips's essential to stay informed about payer policies and updates to ensure you receive timely and accurate reimbursement for your services. The best way to stay informed is by reviewing daily correspondence from payers, including policy updates, claims denials, credentialing status, refunds, appeals outcomes, provider directory data, and demographic data. Policy updates: Payers may make changes to their policies and guidelines, such as new c

One of the first BillingTips's steps to take when following up on accounts receivable is to confirm that the claim has been received by the payer. Most payers have an online portal where you can check the status of your claims, so be sure to utilize this tool. If the claim hasn't been received by the payer, follow up with your billing team to ensure that the claim was submitted correctly. Once you confirm that the claim has been received by the payer, it's important to keep t

As a healthcare provider, it can be frustrating to deal with patients who have outstanding balances that have not been paid despite multiple attempts to collect payment. It is important to understand that collecting outstanding balances is critical to the financial success of your practice. #BillingTips 6: Hire a Collection Agency If a patient has an outstanding balance after receiving three statements, it may be time to consider hiring a collection agency. A collection agenc

If a patient has insurance, they will typically have a deductible and co-pay amounts that must be met before the insurance company will pay for services. Collecting upfront payment for these amounts can help ensure that the patient is aware of their financial responsibility and can help reduce the risk of denied claims due to non-payment. #BillingTips 5: Collect upfront payment for deductibles and co-payments To collect upfront payment for deductibles and co-payments, you can

As a healthcare provider, it is crucial to ensure that your patients have coverage for the services you provide. One way to do this is by reviewing your patients' eligibility and benefits before providing any services. This can help you avoid billing patients for services that are not covered by their insurance, reducing the risk of denied claims and patient dissatisfaction. #BillingTips 4: "Ensuring Patient Coverage: Reviewing EV and Benefits" One tool that can be used to ve

As a medical provider, maximizing reimbursement is essential for maintaining a financially successful practice. One of the most effective ways to maximize reimbursement is by understanding the policies of each payer you work with. Each payer has its own set of rules and guidelines for billing, which can significantly impact your reimbursement rates. By understanding payer policies, you can ensure that you are billing correctly, minimizing denials, and maximizing reimbursement

Medical billing is a crucial part of running a successful medical practice. However, one of the biggest challenges that medical practices face is handling daily EOB denials. When a claim is denied by an insurance company, it means that they will not be paying for the services rendered. Daily denials can lead to a significant loss of revenue, affecting the financial stability of your practice. Therefore, it is essential to learn how to work on daily denials effectively to maxi