The Complete Guide to Medical Billing: How Healthcare Providers Get Paid
Medical billing built for US physician practices
End-to-end revenue cycle management for independent practices and specialty groups — certified coders, 2026-ready charge masters, and no long-term contract.
90 days of your claims analysed by a certified coder. No obligation, no contract.
- CPC-certified coders
- [N]+ EHR/PM systems
- HIPAA compliant + BAA
- No long-term contract
- Onboarding in [N] days
Medical billing services we deliver
Six functions, one accountable team. Most practices hand us the entire cycle — some start with one service and expand once the numbers move.
Revenue Cycle Management
Charge capture, CPT/HCPCS/ICD-10 coding by certified coders, claim scrubbing and electronic submission through your clearinghouse.
Explore serviceDenial Management & Appeals
Root-cause categorisation by CARC/RARC, prioritised work queues, and appeal packages built inside each payer's timely-filing window.
Explore serviceA/R Follow-Up
Daily claim-status chasing on unpaid balances, underpayment detection against contracted fee schedules, and secondary billing.
Explore service Needs own pageCredentialing & Enrollment
CAQH profile management, payer enrollment and re-credentialing, PECOS and Medicaid enrollments, with expiry tracking.
Explore service Needs own pagePrior Auth & Eligibility
Pre-visit insurance verification, benefit and coverage checks, and prior authorizations submitted with the documentation payers ask for.
Explore serviceMIPS / MVP Reporting
Measure selection, data submission and scorecard reporting — including the six new MVPs added for the 2026 performance period.
Explore serviceBilling by specialty
Denial drivers, modifier logic and payer behaviour differ by specialty. We staff each account with coders who bill your specialty every day.
What are unworked denials costing you?
Move the sliders. This uses published industry figures, not our own claims — the same numbers we will measure your practice against.
Denial revenue leak calculator
Industry benchmark model · adjust to match your practice
Methodology: denied charges = monthly collections ÷ (1 − denial rate) × denial rate. Unworked share defaults to 57%, the rate at which Medicare Advantage denials are ultimately overturned (Vabson, Hicks & Chernew, Health Affairs 2024); published industry range is 50–65% never reworked. Rework cost $118/claim. Model uses industry benchmarks, not RevGen client data.
How our revenue cycle works
Five stages, each with a defined owner and a measurable output.
Intake & audit
We take read-only access to your last 90 days of claims, remittances and A/R aging. You get a written baseline: first-pass rate, denial rate by payer and CARC, days in A/R, and underpayment against your contracted fee schedules. Nothing is billed until you have seen the numbers.
Charge-master scrub
We rebuild your fee schedule against the current CPT/HCPCS set, your payer contracts, and your actual allowed amounts. Dead codes are retired, modifier logic is documented per payer, and 2026 changes are applied — including the two separate Medicare conversion factors now in effect for APM and non-APM practices.
Coding & submission
Certified coders work your charges daily. Every claim passes payer-specific scrubbing edits before it leaves — eligibility, NCCI bundling, modifier and medical-necessity checks — so avoidable errors are caught before the clearinghouse, not after a denial.
Denial prevention & appeals
Denials are categorised the day they post, ranked by dollar value and recoverability, and worked inside each payer's filing window. Recurring patterns feed back into step two, so the same error does not cost you twice.
Reporting & A/R follow-up
Unpaid claims are chased on a defined cadence until they pay, appeal, or are formally written off with your approval. You get a monthly scorecard — clean-claim rate, denial rate, days in A/R, net collection rate — reviewed with you on a call, not emailed as a PDF.
Industry benchmarks, honestly cited
We have not published client averages yet, so we are not inventing any. Measure your practice against these instead.
| Metric | US benchmark | Source |
|---|---|---|
| Average initial claim denial rate | 11.8% (2024) | MGMA 2024 Cost & Revenue Report; corroborated by Experian Health 2025 |
| Providers at or above 10% denials | 41% vs 30% in 2022 | Experian Health 2025 State of Claims — 250 revenue-cycle leaders, 23 Jun–3 Jul 2025 |
| Top-quartile denial rate | < 5% | HFMA MAP Keys — widely cited threshold |
| Clean-claim target | 95–98% | HFMA, first-pass acceptance |
| Denials never appealed or reworked | 50–65% | Change Healthcare Denials Index / MGMA |
| Medicare Advantage denial rate | > 17% ≈ 2× traditional | Experian Health 2025; +4.8 pts year over year |
Sourcing notes: the 11.8% figure is 2024 data — cite the year. The >17% Medicare Advantage figure originates in Vabson, Hicks & Chernew, Health Affairs (2024), measuring 17.7% of 270 million MA claim submissions in 2019; for physician/professional claims specifically that study found 14.6%. Use whichever number you can defend.
In-house vs. outsourced: the real cost
The comparison most practices get wrong is salary versus fee. The correct one is fully loaded in-house cost versus what you pay us — and only on money collected.
Outsourced to RevGen
Typically 4–6% of net collections — you pay when you get paid. No recruiting, benefits, PTO or turnover cost sitting on top of it.
Methodology — read this line
$150,500 ÷ 7% of collections implies annual collections of roughly $2.15 million. Below that volume the in-house percentage is higher, not lower. At $1M in collections the same cost is 15%.
- Fixed cost — paid in full whether claims go out or not
- Recruiting, training and turnover risk sits with you
- PTO, sick leave and resignation create coverage gaps
- One person holding payer-rule knowledge is a single point of failure
- Coding updates depend on whoever happens to be in the seat
Frequently asked questions
How much do medical billing services cost in the US?+
Most US billing companies charge one of three ways: a percentage of net collections (the most common), a flat fee per claim, or a monthly retainer. Percentage pricing typically lands between 4% and 8%, and the number moves with your specialty, average charge per claim, claim volume, payer mix, and how much legacy A/R you are handing over.
Watch the definition behind the number. A headline 5% charged on gross charges is not the same as 5% of what you actually collect — the second can cost materially more. We quote on net collections and put the definition in the agreement.
Do you work with my EHR or practice management system?+
Almost certainly. We work inside the systems practices already run — including Epic, athenahealth, eClinicalWorks, NextGen, AdvancedMD, DrChrono, Tebra, OfficeMate, ModMed/EMA, NueMD, ChiroTouch and WebPT — and through the major clearinghouses. You do not need to migrate your software to work with us.
We request role-based access rather than a shared login, and we document the specific workflow in your system during onboarding.
How long does it take to switch billing companies?+
Plan on two to three weeks from signed agreement to live claim submission. Week one is credentialing and payer enrollment verification, clearinghouse connection, fee-schedule import and template setup. Weeks two and three are test claims, staff handover, and going live.
Your existing A/R does not stop in the meantime. Practices that also need CAQH updates or new payer enrollments should allow an additional 30–90 days for those items, which run on payer timelines rather than ours.
What is a good first-pass clean claim rate?+
95% to 98% is the widely used target for first-pass claim acceptance. Below 95% usually means a front-end problem — eligibility verification, missing modifiers, bundling edits or authorisation gaps — rather than a payer problem.
We measure your baseline during the free audit and report against it every month. If your current provider cannot tell you their own clean-claim rate for your account, that answer is itself useful information.
Are you HIPAA compliant and will you sign a BAA?+
Yes, and yes. As a business associate handling protected health information we sign a standard Business Associate Agreement before any PHI changes hands — not after, and not as an optional extra.
On the operational side: encryption in transit and at rest, role-based access controls, audit logging, workforce HIPAA training, and a documented breach-notification procedure.
Do you require a long-term contract?+
No. We work on a rolling month-to-month basis with 30 days' written notice to end the engagement. There is no early-termination fee.
You keep your clearinghouse account, your payer enrollments, and full export access to your claims history, remittances and A/R reports. If you leave, you leave with everything.
Which specialties do you bill?+
We have dedicated service pages for cardiology, orthopedics, behavioral health, internal medicine, pain management, nephrology and OB/GYN — see our specialties page for the full list.
Every specialty has different denial drivers. Therapy modifiers, global surgical periods, parity rules, MCP billing for dialysis. We staff each account with coders who work that specialty routinely, and if yours is not a fit we will say so rather than take the account and underperform.
Do you handle credentialing and prior authorizations?+
Both, as standard services rather than add-ons. Credentialing covers CAQH profile creation and maintenance, initial payer enrollment, re-credentialing cycles, PECOS, Medicaid enrollment, and expiry tracking so nothing lapses without warning.
Prior authorisation covers payer-specific requirement lookups, submission with the supporting clinical documentation, status tracking, and appeal when an authorisation is denied.
Get your free medical billing audit
Ninety days of your claims data, analysed by a certified coder. You get a written report showing exactly where revenue is leaking — whether or not you ever hire us.
- First-pass clean-claim rate
- Denial rate by payer and CARC
- Days in A/R and aging buckets
- Charge-master gaps
- Underpayment vs. contracted fees
Prefer to talk? Call (207) 881-1046 or email info@revgenbilling.com