Billing, The Life Blood of Your Practice

What Is Medical Billing?

The US healthcare system is a third-party payer system in which care providers submit claims to insurance companies or government agencies (Medicare and Medicaid) for services rendered to patients. Physicians notate diagnoses derived from the visit and treatments performed during the encounter in the patient’s medical record, and medical coding experts use standard codes known as ICD-10 to create a bill or insurance claim for those services to be sent to the insurer for reimbursement.[1]

Until about 20 years ago, physician billing was done almost exclusively on paper. Today, standalone billing applications or billing modules built into practice management software are used by virtually all care providers. Some providers hire medical billing experts to create claims and follow up with insurers regarding denied or rejected claims; others outsource the medical billing function to a third-party service or company that specializes in medical coding and billing.

Billing Process

Healthcare practitioners contract with insurance companies to provide patient care services, and the rates for those services are pre-negotiated. Following each patient visit, the provider charts the diagnoses and treatments that should be billed, and a coding expert assigns the appropriate diagnosis and procedure codes to create a claim. The claim is sent electronically to the insurer, either to a private insurance carrier, or government entity such as Medicare, Medicaid, Tr-Care (Veterans), or Railroad (retired federal workers). Often, the claim goes first to a clearinghouse, which scrubs the claim to make sure there are no errors or omissions, and that the codes are valid to the patient type, and that the procedure codes are appropriate for the diagnosis code submitted with it.[2]

Once a clean claim makes it to the health benefit payer, approved claims are reimbursed based on the pre-arranged agreement. Claims will be rejected (not processed) if the patient’s personal information is inaccurate (e.g., name, date of birth, and identification number do not match) or the claim contains errors such as invalid or truncated diagnosis or procedure codes. Rejected claims must be corrected and resubmitted. Claims will be denied if the insurer processes a claim and finds it to be not eligible or otherwise payable. The insurer must inform the provider about the reason for the denial, and the provider can appeal the decision.[3]


A claim can be denied for a variety of reasons.[4] The most common mistakes leading to denial are:

  1. The coding was not specific enough. For example, simply diagnosing a patient with diabetes is insufficient. Instead, the code for a specific type of diabetes must be entered.
  2. The claim was missing information such as the date of accident/medical emergency or the date of onset.
  3. The claim was not filed on time. The Affordable Care Act reduced the claims-submittal period for Medicare from 15 to 27 months to 12 months. A claim must be received by the appropriate Medicare claims processing contractor prior to the end date, which is exactly one calendar year after the start date (the “From” date on the claim form).
  4. There were coding issues resulting from using an outdated code book or a biller incorrectly interpreting a provider’s handwriting.
  5. The claim lacked proper documentation. Each payer has its own definition of the medical records it requires before it will adjudicate a claim. It’s the medical biller’s specific responsibility to keep track of and understand payer requirements and submit the documentation needed to support the level of service performed.
  6. The claim contained duplicate items, which can result from multiple same day visits, or resubmitting a claim instead of submitting a follow-up claim, or cancelling a procedure or test but not removing it from the patient account.
  7. The claim contained a higher code than is typical for the diagnosis, such as a code for a higher-paying service than would be expected. Referred to as upcoding, and done repetitively this can be considered fraud and is thus illegal. Payers will automatically deduct funds from a doctor’s account in order to recover overpayments.
  8. The claim contained unbundled tests or procedures. Known as unbundling, this practice involves billing separately for tests or procedures that are required to be billed together and is also illegal.
  9. Prior authorization was needed. Although prior authorization is not a guarantee of payment, it’s critical to obtain one for any visit or treatment the patient’s insurer specifies as requiring it.
  10. The patient’s benefits were not eligible or coverage was terminated. Insurance information can change at any time, so it’s vital to verify eligibility on the day of service to make sure the patient’s coverage has not been terminated and their maximum benefit has not be met (e.g., for physical therapy and behavioral health).


The time from a patient visit until full payment is received can be weeks or months. The billing cycle, known as the revenue cycle, can involve several interactions between the healthcare provider and insurance payer. If the patient is responsible for a portion of the visit, that bill must also be generated and collected on. The longer the revenue cycle, the more difficult the provider’s cash flow is to manage. Such is the case in a workman’s compensation claim, a prolonged hospitalization, or an auto accident, which is why revenue cycle management controls are included in the more advanced practice management software systems and why some providers outsource complex or difficult billing to third-party billing companies that have the expertise to speed up the payment cycle.[5]

The payment process is further complicated by the fact that providers typically charge more for services than what has been negotiated by the physician and the insurance company. The amount paid by the insurer is known as the allowable amount, and the difference between what was billed and what was paid is know as a provider write-off or contractual adjustment. The insurance payment will be further reduced if the patient has a copay, deductible, or coinsurance. The provider is typically responsible for collecting this amount from the patient.[6]

The amounts patients are responsible for have risen steadily over the last decade and continue to do so. In 2017, patients were responsible for 12.2% of their total healthcare bill, compared with 8% of their bill in 2012.[7]

The chart below demonstrates that the need for an experienced biller along with solid revenue cycle management software begin with the very first claim. It then rises at a one-to-one ratio as claim volume increases.

The Role of Software

Modern medical coding and billing software is designed to help billers quickly create a claim that ensures accurate patient information and correct codes for the visit. It also provides secure storage of patient health information and financial information and the ability to electronically submit claims to payers. Software packages may also provide:[8]

  1. Accessibility from any device with access to the internet
  2. Automatic updates as coding rules and regulations change
  3. Multiple choices for patient look-up (name, date of birth, etc.)
  4. Ability to easily create patient statements
  5. Ability to create customized letters to payers, work-comp, attorneys, and patients
  6. Clearinghouse integration within the practice management system
  7. The ability to track unapplied money and monitor write-downs
  8. The ability to create payment plans for patients
  9. The ability for providers to quickly review claims for accuracy and make suggestions for fixing denied claims (claim scrubbing)
  10. Insurance balance report that shows the patient information and payer contact
  11. The ability to manage collections for improved cash flow
  12. The ability for front-office staff to view patient balances, enter patient demographics, and enter insurance information from the scheduling module
  13. Integration with the practice’s electronic health record (EHR) so coders can view the medical notes and create the most accurate bill possible
  14. The ability to help administrators manage the revenue cycle via a claims-performance dashboard and integration with the practice management system

Medical Billing Services

There are many drivers for outsourcing a practice’s billing function. For example, some providers seek to reduce the number of administrative tasks being performed in-house and the costs associated with them, including personnel, computers, and secure offsite electronic storage, and office space. Other drivers include:

  • Better integration between billing, patient records (EHR), and practice management systems
  • A desire to speed up the revenue cycle, reducing the time it takes from claim creation to payment
  • Reducing the need to continuously track changes in medical billing regulations
  • A desire to ensure all bills are maximized in terms of insurance payments

A tangible and equally important driver of outsourced physician billing is the desire to decrease time spent on administrative tasks in order to increase time spent with patients.

The Life Blood of Your Practice

advanced office software

Successful Insurance Billing and Patient Collections

Insurance billing amounts to 70% – 80% of the typical practice’s income. Patient pay, in term of co-pays, deductibles, and self-pay account for the rest. A finely tuned billing department is no accident. It all begins with a well organized front office, efficient workflows, clearly articulated policies and procedures, and the systematic enforcement of best practices.

The key to an optimal “patient-to-pay” process is advanced office software that streamlines every aspect of the medical billing continuum and puts in place the needed checks and balances that create efficiency and insure tight financial control.

Cash flow is the lifeblood of your medical practice. If patient collections are off or receivables are unattended, profitability is headed downward. Here are seven keys to improving cash flow in your practice:

  • Educating Personnel
  • Utilizing Technology
  • Using a Clearinghouse
  • Monitoring Rejections
  • Managing Denials
  • Monitoring A/R for Accurate Insurance and Patient Payments
  • Utilizing Metrics to Measure Productivity

Organizing Your Front Office

When you bundle the best techniques of successful practices into one easy-to-use practice management software platform, you gain control of your patient payments, claims billing, and receivables. Here’s how:


Front Office Tasks

Scheduling: Everything begins with the patient appointment. Here is a detailed process flow chart of a typical patient visit. Quality control is a key factor in each event.

1)Patient Management
a) Pre-visit: Verify benefits.
b) Estimate patient responsibility (Patient Consult)
c) Obtain prior authorizations

2)Staff Scheduling
a) Personnel scheduling
i) Multi-location scheduling needs
b) Equipment and Resource scheduling

a) Print forms
b) Print labels, schedules, and charge-slips (superbills).

4)Patient Check-in
a) Registration
i) Recheck benefits
ii) Pull charts
b) Intake Forms:
i) Medical history
ii) Family history
iii) Prescription history
iv) Personal habits history (smoke, drink, etc.)

5)Patient Payments & Cash Mgmt

6)Pre-Exam: Vitals. Chief Complaint. Enter Hx history into EHR.
a) Upgrade status to: Ready for physician/exam.

With flexible appointment scheduling software, you can easily find next available time-slots, schedule resources, and print patient’s visits. Appointment reminders help eliminate costly missed appointments.
All Scheduling Features

Eligibility & Authorizations

Verifying health benefits before the arrival of the patient is essential not only to the revenue cycle but to patient care as well. Real-time eligibility can be checked instantly at the point of care or automatically each night in batch. Electronic authorizations are available through Emdeon and RelayHealth. You can review the patients complete eligibility verification history. And each detailed reports shows active coverage, copay, annual deductible & Co-insurance for various type of services.


Upon arrival, good software insures a smooth office flow, but it also insures that patient pay is collected along with any open balances. Advanced office software can help improve patient wait-times by alerting doctors to waiting patients and keeping staff abreast of a patient status at all times.

Here are a few scheduler highlights!

  • Simple and easy Scheduler interface
  • Color Code Appointment by Status
  • Predefined Appointment time slots: e.g. 30 Minutes for new patient, 15 minutes for follow-up, etc
  • Built-in Eligibility Verification
  • Single click option to view weekly or daily schedule
  • Search patient appointments instantly
  • Multiple appointments on the same time slot
  • Keep multiple appointment screens open while you navigate to other areas of the application
  • Easy to set follow-up and recurring appointments
  • Ability to generate forms, superbills, patient labels or patient demographics from scheduler
  • Instant access to patient financial summary
  • Instant access to patient ledger, statements etc from scheduler.
  • Block single, multiple or recurring appointment time slots for a specific Provider
  • Block single, multiple or recurring appointment time slots for the whole Practice/Entity
  • Customize appointments by name for multi-providers practices with supervising physician
  • Schedule Resources/First Available


  • Find Patients Instantly
  • User Definable Time Slots
  • Unlimited Color Coding Options
  • Multiple View
  • Appointment Scheduling Report
  • Auto generate custom Missed / Cancelled Appointment Letter
  • Generate Superbills
  • Auto generate custom Recall Letter
  • Comprehensive Patient Demographics
  • Label Generator
  • Self-learning Appointment Reasons
  • User Defined Status and Status Coloring
  • Easy click Follow-up and multiple recurring
  • Capture Surgery and other notes per appointment

Large Facility Enterprise Features

  • Multiple Locations
  • Multiple Tax Ids
  • Multi-specialty
  • Resources and Equipment
  • Scheduling
  • Comprehensive Patient ledger
  • Track: Changes, and Cancellation
  • View Appointment Hx
  • Print future appointments
  • Enter Insurance Details
  • Customizable Superbills per Provider
  • View Patient Balance & Co-pays
  • Track Cancelled & Missed Appointments
  • Track Changed Appointments
  • Track Superbills
  • Enter Co-pays and Payments from Calendar
  • Print Receipts
  • Track missing Co-pays
  • Extensive Notes per Patient Visit
  • Double, Triple Appointment booking
  • Set Recurring Appointments
  • Add Unlimited Providers to Scheduler
  • Easy Maneuvering Between Providers and locations
  • Search for Open Time Slots
  • Adjust Time Slot for Individual Appointments
  • Missed Copay Report
  • Missing Superbill Report

Practice Portal

The role of a patient portal in appointment scheduling is to allow patient to schedule pre-designated time slots online and avoid tying up staff time and phone lines. In the back end billing process it is to notify patients of balances and provide an easy way to make payments, thus avoiding collections and unpaid balances.

  • Custom Website Content
  • Online Scheduling
  • Online Availability
  • Online Medical Records
  • Credit card processing
  • End of Day Reconciliation of Front Office Payments
  • User Audit Trial
  • Remote user access restriction

lnstant Insurance Eligibility Verification

  • Connects with 1300+ payers including Medicare and many state payers
  • Instant Eligibility History
  • View Copay, coverage and other vital insurance information

Robust and Powerful Appointment Reporting

  • Appointment Schedule Report
  • Appointment Worksheet Report
  • Appointment Status Report
  • Appointment – End of Day Reconciliation Sheet Report
  • Missed/Cancelled Appointments Report
  • Patient Examination Summary Report
  • Eligible Visits Bill Report
Patient Satisfaction plummets when wait-times skyrocket due to staff and providers having to guess about a patient’s status or whereabouts. Know where your patient is at all times and communicate it clearly to staff using our Inter-Office Communications Module. Afterwards measure, track, and report on patient wait times to improve office efficiency.

Patient Status Include:

  • Arrival Time
  • Check-in Time
  • Vitals & Room Status
  • Ready for Exam – Physician Notified
  • Labs, Orders, Recalls.
  • Referral Station
  • Check-out, Payments
  • Departure time

Clinical Care Management

The role of EHR in the billing process is critical as all medical coding depends on and is taken from the clinical note. When you try our EHR, you’ll find yourself thinking how charting could be so easy and so natural. As simple as charting on paper, our entire clinical workbench is laid out on a single screen that is easily navigated on a Tablet, iPad, Desktop, or Notebook. In fact the entire patient record is on one single screen and is designed to let you chart using voice recognition, a stylus, a keyboard, or all of the above.

Affordable and proven to work for General Medicine and +61 medical specialties, PracticeSuite’s simple and intuitive EHR allows you to document encounters in seconds with a uniqueSingle Screen Design thatgives the the look and feel of paper charting; and you can easily customize encounter sheets and forms to tailored to your needs. Where appropriate, you can quickly copy the patient’s last note, modify, and save it in seconds. Most importantly, billers have instant access to patient notes for medical coding.

The Clinical Encounter Process

8)Exam/Review of Systems
a) Record (chart) findings
b) Orders (Rx, Labs/Rad, Drug Interactions & Formularies).
c) Referrals.
d) Consultation Sheets. Document mgmt. Growth Charts
e) E&M coding assistance
f) e-Superbill: Auto-creates charges on hold for review

9)Task Assignment: Inter-office Communication. Team coordination of care

Scan and Store Documents Within the Patient Record:

  • Incoming faxes create an automatic ticket and PDF attachment
  • Sent emails or faxes automatically create a ticket
  • Create links with super-bills, images, and other documents to reference scanned documents
  • Assign tickets to staff to monitor, communicate with client, or other staff
  • Maintains a complete step-by-step audit trail
  • Monitor open tickets and effectively manage office workload

Used effectively by both solo providers and by large medical groups, this highly flexible EHR supports Team Care, Multi-Specialty, Multi-location, and Multiple Tax IDs ––all within the same group or practice.

Some EHR Feature Highlights:
  • ICD-10 Operational: Select familiar ICD-9 codes and learn ICD-10 while you chart
  • Perfect for Tablets, PC’s, Laptops, Android, Apple, iPad, Safari, and Mac.
  • Easy to learn and adopt. Encounter sheets are easy to customize.
  • Document multi-condition, multi-problem visit without the use of restrictive templates
  • Use voice recognition, a keyboard, stylus, or a mouse.
  • Single screen design allows access to entire patient record without changing screen
  • E&M Coding. Clinical Decision Support (CDSS). Quality Reporting (PQRS). Computerized Order Entry (CPOE).
  • ONC-ATCB Certified Stage 2 Complete EHR
  • To-do list, Inter-office and intra-office communication (communication between locations).
  • Electronic Superbill that’s completely integrated with appointment scheduling and billing

Documenting a patient encounter is half the challenge. Getting that information into the hands of other doctors and staff in a timely manner can be a greater challenge.Modern EHR systems are fully equipped with a powerful document management module that manages charts, scans, faxes, and email in a robust, workflow-based, secure tracking system.

Prescribe, Order, Fax

You can quickly review formularies, pharmacy locations, order, and fax all from within the patient record with little or no bouncing from screen to screen.


PracticeSuite billing and EHR software has a powerful Inter-office communications module that allows you to assign tasks to any user in your practice – across multiple offices and locations, and set reminders and alerts to keep your tasks on track. Save a medical record as “For Review” and assign it to another doctor to add their notes, and when the note is complete, save it as “Complete”.

Order, e-Prescribe, eFax, Email

  • Transmit electronic prescriptions to +70,000 pharmacies (Surescripts)
  • Receive electronic lab results from most national labs: Quest, Lab Corp, etc.
  • Fax within the patient record with integrated e-Faxing
  • Email within the patient record with secure email
  • Push lab results, referrals, and any other communications to a patient’s Patient Portal account

Insurance Billing

According to the AAPC the average claim error rate is above 40% on a first-time insurance claim. When analyzed, the top 20 billing errors involve minor details: Such as the proper address for the insurance, a patient’s date of birth, or failing to signify male or female. The average denial rate is above 25%and 48% of denied claims are never followed up– leaving the bulk of a practice’s profits left uncollected. Furthermore up to 25% of a practice’s revenue is now patient pay.

Improving Claims Management

With our claims management software, you can submit electronic claims in a matter of seconds. Control the entire claims management system from any location with an internet connection. An automated claims scrubbing system double-checks all claims for errors, significantly reducing denied claims. Coding reference is included, so you can stop buying expensive code books. ICD-10 ready! Print CMS-1500 claims, or submit primary and secondary electronic ANSI 837 claims so you can track the status of your claims.

Improving Patient Pay

The failure to collect patient pay at the point of care can result in an expensive and inefficient collections process. The goal is a 90% or better patient-pay collections rate. To ensure this, PracticeSuite’s Pulse Money Monitor keeps guard over every patient visit to make sure open balances and co-pays are collected upon the patient’s arrival.

Improving Billing

With PracticeSuite, your practice can instantly achieve a 94% first-pass claims success rate. We accomplish this through a combination of Front-End Edits that ensure that every claim is payer-ready before it’s sent. Our system also automatically checks eligibility. And while verifying eligibility is no guarantee that a claim will get paid, it ensures that the patient’s treatment is covered by their benefits and that your appeal for medical necessity will have a far higher chance of success.

Classic Back Office Functions

10)Check-out: Collect patient balances.
a) Referral Desk. Recalls

11)Post Check-out:
a) Finalize and create insurance charges
i) Clinical notes avail in Charge Entry screen

Creating Charges:
In modern software, medical claims are often created in a semi-automated way from data taken from the physician’s clinical notes, and are then passed through a claim validation and scrubbing engine that checks the charges against local and regional payer rates, CCI edits and CMS edits. They then go to a medical biller for spot review, hand edit, and charge approval.

Approved claims are then batched and transmitted securely to an clearinghouse (EDI) for secure transmission to the health insurance payer. At which point they are watched closely for rejection due to errors on the claim, payment delays, or payer denials.

12)PM & EDI: Integrated Clearinghouse functionality
a) Secure claim transmission to payer
i) 11 claim status codes

13)Postinginsurance payments and patient payments.
a) Secondary insurance claims
i) Adjustments & Write-offs
ii) Insurance balances visible in appointment calender

14)Patient Balances/ Pre-Collections
a) Soft collection letters.
b) Patient balances displayed in patient ledger and appointment scheduler

a) In-house vs Outsourced.
i) Write-downs

Pursuing Revenue

The surest way to decrease collections and minimize A/R is by collecting as high a percentage of revenue upfront as possible by collecting patient-pay, and making sure the patient’s benefits were checked and authorizations were obtained prior to treatment to reduce claim rejections and denials. Keeping open patient balances at a minimum and appealing denials quickly and persistently helps keep receivables low.

With PracticeSuite Claims Management software, you can accelerate the collections process with customizable work queues, automated insurance collections ticklers, and comprehensive tracking tools. Efficiently follow-up on denials and non-response claim rejections with our easy option for single or bulk resubmit. All necessary information for claims follow-up is available on a single screen.


  • Reduce your outstanding A/R days
  • Improve billing efficiency
  • Reduce billing cost
  • Improve cash flow
  • Get paid in a timely fashion
  • Faster reimbursement
  • Integrated claims correction and online reference tools
  • Centralized financial reporting
  • Reduce redundant data entry
  • ERA and auto posting
  • Claims submission and tracking
  • Denied claims management

Real-time Revenue Monitoring

Something you will find only at PracticeSuite are real-time Revenue Cycle Management Monitors that alert you when:
  • Patients are checked-in but eligibility is unchecked
  • Co-pays / patient pay are uncollected
  • Appointments are deleted, canceled, moved, missed, etc.
  • An unauthorized visit or procedure is about to happen
  • Patients have been seen but remain unbilled
  • Balances above your preset threshold are written off
  • Timely filing presets are ignored
  • Claims or denials are not followed up
  • Collections performance is below preset threshold
  • We monitor User productivity, and offer User productivity reporting

Denial Management

  • ERA auto-posts denials and under payments
  • For manual EOB/payment, enter $0 payments with 5010 compliant denial codes
  • Run Denial Reports
  • Denials get posted to collectors in Collections/Follow-up workbench
  • Complete end-to-end workflow to track follow-up and collections activities
  • Run Reimbursement Analysis Report to compare under payments against contract schedule
  • Small balances can be written-off or adjusted through Mass Adjustment Module with custom defined or pre-defined adjustment codes

Installments/Payment Plan Management

  • Easily schedule patient payment plans
  • Easy access to View/Print payment plan activities
  • Easy access to print letters to patient on payment plan screen
  • Patients on Payment Plan are excluded from statements cycle
  • List / View all Patients added to the Payment Plan
  • Print/View payment plan details

Statement Management

  • Generate Statements using robust and flexible criteria
  • Unique identifier for each statement
  • Easy access to snapshots of each statement
  • Complete Statement History with details
  • Print patient friendly statements
  • Customizable downloadable format for third-party printing
  • Easy access to statement history
  • Print statement from Scheduler & Patient Ledger
  • Easy access to Last Statement Date and Last Payment date from Ledger
  • Print Statement by Guarantor (Individual/Entity)
  • Search and Post Patient Payments by Statement #number
  • Complete audit trail of statements: View, Export and Print
  • Multiple print formats to choose from

Pre-Collections Management

  • Ability to transfer patients to Pre-Collection status
  • Ability to generate Pre-collections Letters
  • Pre-Collection patients are excluded from statements cycle
  • Easy access to view and print patients in Pre-Collections status
  • Downloadable format for third-party printing
  • Configure alerts easily

Write Off Management

  • Predefined and custom defined write-off types
  • Standard contractual v/s other write offs are entered and tracked separately
  • Write-offs at line level for granular tracking
  • Write-off reporting (Detailed and Summary)
  • Capitated HMO claims are written-off automatically after successful submission

The Right Practice Management Software!

Nine Reasons to Choose the PracticeSuite Platform

Access Anywhere!

Web Browser Access.
Advanced User Security.

Avoid Re-Enrollments

Keep Existing
Clearinghouse and Avoid
Enrollment Hassles.

Increase Patient Visits

Improve Revenue with Tools to
Reduce No-Shows and Increase
Patient Satisfaction.

Expand Online Services

From Appointments,
to Communication, to Online Bill Pay,
and Kiosk Services.

Improve Collections

Better Claim
Acceptance and Easier
Denial Management Tools.

Stop Losing Revenue

Dashboard Alerts Help
Stop Financial Bleeding.

Improve Performance

Advanced Reporting and Key
Performance Measures Show
Areas for Improvement.

Your EHR Choice

Pick PracticeSuite’s
EHR or Connect with Our
Leading EHR Partners.

Decrease Costs

Sophisticated, yet
Affordable Software Tools
for Your Practice.

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