Explore MedSole RCM’s blog for tips, industry updates, and billing insights. We share valuable content for providers looking to strengthen their revenue cycle. Stay informed with content made for healthcare professionals.
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The financial health of a healthcare organization depends heavily on its ability to manage revenue efficiently. From patient registration to final payment, every step in the revenue cycle requires careful attention. At MedSole RCM, we provide focused medical RCM solutions designed to support hospitals, clinics, and private practices in handling billing complexities while maintaining compliance and accuracy.
As healthcare regulations and payer requirements grow more complex, many providers struggle with delayed reimbursements, coding errors, and rising administrative burdens. Our RCM solutions in medical billing address these challenges with systems and support that allow practices to focus more on patient care and less on paperwork.
Whether you run a large hospital or a small clinic, having dependable revenue cycle management is critical to long-term sustainability.
Hospitals often face high claim volumes, multiple departments, and a mix of payers that require dedicated support. MedSole RCM offers RCM solutions for hospitals that include:
Hospitals face unique RCM challenges: high-volume claims, multi-department billing, and stringent compliance requirements. RCM solutions for hospitals must address:
MedSole’s Approach: Real-time analytics dashboards tracking A/R days and denial trends across all service lines.
Our solutions are built to adapt to the operational and financial workflows of large healthcare organizations.
Independent practices often encounter billing challenges that can lead to revenue loss if not properly managed. Our RCM solutions for medical practices are designed to be clear, efficient, and responsive, supporting specialties like internal medicine, family practice, behavioral health, and more.
Services include:
Smaller practices struggle with limited resources and payer policy shifts. Effective RCM solutions for medical practices provide:
We help medical practices regain control over their billing processes and stay financially stable.
At MedSole RCM, we believe in clarity, consistency, and reliability. Our team understands the pain points in healthcare billing and offers medical RCM solutions that help reduce errors, speed up collections, and bring visibility to every step of the revenue cycle.
MedSole RCM: Your Partner in Revenue Resilience
We resolve critical pain points:
From claims to collections, our support is centered around helping your practice get paid accurately and on time.
In today’s healthcare environment, it's no longer enough to rely on manual or outdated billing processes. Reliable RCM solutions in medical billing help protect revenue, reduce administrative burden, and allow healthcare providers to focus more on what matters — patient care.
Whether you're looking for RCM solutions for hospitals or specialized support for your private practice, MedSole RCM is here to guide your financial performance in the right direction.
Experience the MedSole RCM difference. Request a free consultation today.
Ans: Medical RCM (Revenue Cycle Management) solutions help healthcare providers manage the financial side of patient care—from insurance verification to final payment. They are essential for reducing revenue leakage, ensuring timely reimbursements, and maintaining compliance.
Ans: Hospitals often face complex billing due to multiple departments and higher claim volumes. RCM solutions for hospitals include advanced denial management, interdepartmental coordination, and compliance audits. In contrast, medical practices require more streamlined, specialty-focused billing and support for credentialing.
Ans: MedSole RCM addresses claim denials with proactive root cause analysis, accurate coding, real-time eligibility checks, and dedicated follow-up teams. Our systems are designed to reduce denial rates by up to 45%.
Ans: Yes, MedSole RCM offers scalable solutions for independent practices. Our services include automated eligibility verification, transparent patient billing, and ongoing compliance updates—requiring no upfront tech investment from your practice.
Ans: We accelerate the reimbursement cycle by submitting claims within 24 hours after scrubbing for errors, tracking real-time statuses, and maintaining strong payer follow-up protocols. This helps minimize delays and improve cash flow.
Ans: You can contact our team for a free consultation to evaluate your current revenue cycle and explore how our medical RCM solutions can improve your financial performance.
Revenue Cycle Management (RCM) is the financial backbone of every healthcare organization. From patient registration to final payment, every step in the billing cycle impacts cash flow, efficiency, and profitability. However, without accurate and timely reporting, decision-makers are left guessing. This is where RCM reporting becomes essential not just for visibility but for strategic growth.
At MedSole RCM, we’ve worked with clinics, private practices, and specialty providers to improve their financial outcomes through focused reporting practices. With the right data in hand, healthcare leaders can uncover inefficiencies, reduce claim denials, and make data-driven decisions that lead to long-term financial health.
RCM reporting refers to the structured collection and analysis of data throughout the medical billing process. These reports track performance metrics such as claim approval rates, denial reasons, days in accounts receivable (A/R), reimbursement speed, and payer trends.
Unlike generic financial reporting, reporting in medical billing dives deep into operational bottlenecks, allowing organizations to take corrective action before revenue is affected.
Without visibility, it’s nearly impossible to improve. Medical billing reporting services give providers the data they need to:
According to the Healthcare Financial Management Association (HFMA), more than 60% of denied claims are recoverable but only if providers have systems in place to detect and address them early. RCM reporting makes this possible.
A solid reporting process in healthcare revenue management typically includes:
These reports highlight the number of charges entered and missing charges by provider or department, giving insight into potential revenue loss due to under-coding or overlooked services.
Track how many claims were sent to each payer, when they were submitted, and the status of each providing transparency into claim processing speed and accuracy.
Understanding denial reasons helps practices correct recurring issues. Whether it's coding errors, invalid patient information, or eligibility problems, denial reports are crucial for loss prevention.
Accounts receivable reports show how long balances have been outstanding. Practices can use this to prioritize follow-ups and maintain steady cash flow.
These allow providers to evaluate how different payers are reimbursing over time and help in negotiating better payer contracts.
Avoid these common pitfalls when adopting RCM reporting:
Data overload → Focus on 5 critical KPIs first
Isolated reports → Integrate with EHR/PMS
Historical-only views → Add predictive analytics
Static PDFs → Use interactive visualization tools
At MedSole RCM, our medical billing reporting services are built around transparency, accuracy, and clarity. We provide our clients with detailed dashboards and scheduled reports that help them monitor:
Our goal is not just to deliver data, but to deliver usable insights that translate into action. Practices can use these reports to allocate resources, set realistic financial goals, and eliminate guesswork from critical decisions.
Beyond day-to-day operations, RCM reports help practices plan long-term. With real data, leadership can:
Data-driven decision-making isn’t a luxury in modern healthcare, it’s a necessity.
In the evolving world of healthcare, data isn’t just about numbers, it’s about direction. RCM reporting gives healthcare providers the clarity needed to make smarter financial decisions. Whether you run a solo practice or a multi-specialty clinic, understanding the details of your revenue cycle can lead to improved collections, reduced denials, and better planning.
At MedSole RCM, we believe in giving you the tools to take control of your revenue. Through precise medical billing reporting services, we turn raw data into real insight helping your practice grow with confidence. Let MedSole RCM turn your billing data into actionable insight. Contact us today.
RCM reporting refers to the process of collecting and analyzing data from different stages of the revenue cycle to track financial performance and identify areas for improvement.
By providing visibility into the reasons claims are denied, RCM reports allow practices to fix recurring issues such as incorrect coding or eligibility errors leading to higher approval rates.
Some of the most vital metrics include days in A/R, denial rates, net collection rate, claim turnaround time, and clean claim rate.
Absolutely. Even solo practitioners can gain valuable insights from structured reporting, especially to detect revenue leakage and manage payer relations effectively.
Ideally, practices should review key reports weekly and conduct in-depth reviews monthly or quarterly to assess performance trends and make adjustments.
Basic reports show static numbers (e.g., "total denials"). Advanced RCM reporting reveals patterns, causes, and solutions.
Yes—MedSole RCM connects with major platforms like Epic, Cerner, and AthenaHealth for automated data sync.
A/R Aging Report. It shows unpaid claims by timeframe (0-30/31-60/61-90/90+ days), directly indicating cash flow health.
Advanced systems detect emerging issues within 72 hours (e.g., sudden denial rate increases or payment delays).
Medical Administrative Contractors (MACs) play a critical role in healthcare reimbursement specially in Medicare system. Understanding of MAC is very important for all healthcare providers and medical billing professionals, because it helps in claim submissions, appeals, payments, and policies efficiently.
This blog explains what MACs are, how they function, and their role in medical billing processes for healthcare providers under Medicare.
A Medical Administrative Contractor (MAC) is a private healthcare insurer, organization or multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims. These contractors manage a vital portion of the administrative processes for Medicare beneficiaries, providers, and suppliers.
MACs perform many activities including:
Across the whole United States there are different MACs for various regions, each assigned to handle specific geographic area.
Before MACs, Medicare relied on a fragmented system. However, in 2003, the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) reforms the structure. CMS integrated its administrative contracts into MACs to improve service, reduce costs, and create more accountability.
The main goals behind establishing MACs include:
MACs are divided based on jurisdictions that cover both Medicare Part A and Part B. There are:
Each jurisdiction has a designated MAC responsible for servicing providers in that region. Providers must submit claims to the appropriate MAC based on their practice location.
MACs serve as the important connection between healthcare providers and CMS. Here’s how they impact and assist in the medical billing process:
MACs receive claims from healthcare providers for Medicare services. They review claims to ensure they meet medical necessity and documentation before processing them for reimbursement.
Providers must follow MAC-specific instructions on:
MACs manage the enrollment process for new providers into the Medicare program. They verify credentials, tax identification numbers (TIN), NPI numbers, and practice locations to ensure the authenticity of providers applying for Medicare Billing rights.
The process is important for getting reimbursement by Medicare. The provider’s ability to receive payment will directly be impacted because of delays or errors during enrollment.
When claims are reviewed and approved then MACs are responsible for issuing payments to healthcare providers. They also provide Remittance Advice (RA) documents.
Understanding these remittances helps billing teams to appeal denied claims or correct errors for resubmission of claims.
If a claim is denied, the MAC explains the reasons for denial. Providers can then file an appeal or resubmit a corrected claim with denial management strategies.
Having clear communication with the MAC and understanding their procedures of appeal is important for minimizing revenue loss due to denials.
MACs also implement Local Coverage Determinations (LCDs) policies that explains what services are covered within their geographic area. These LCDs often vary by region and effects what procedures or treatments are considered reimbursable.
Providers must stay up to date with their local MAC's policies to avoid claim denials.
MACs regularly offer:
Working with MACs helps providers in several ways:
Medical billing companies and internal billing departments must build strong relationships with MACs for operations, reduction in denial rates, and accelerate revenue cycles.
Having a good billing team or partnering with a professional revenue cycle management company can help healthcare providers overcome these issues and maintain financial stability.
Medical Administrative Contractors plays important role in success of Medicare billing. Their role in claim management, provider enrollment, policy enforcement, and education make them essential in today’s healthcare reimbursement system.
At MedSole RCM, we work closely with providers across the U.S. to manage their Medicare billing processes effectively, guaranteed proper communication and compliance with their assigned MACs. Whether it’s about claim submission or appeal handling, we’re here to support your practice in every step of the process.
1. What is a Medical Administrative Contractor (MAC)?
Medical Administrative Contractor (MAC) is a private organization that works with CMS to process Medicare Part A and Part B claims. It handles provider enrollment, manage appeals, and implement billing guidelines across the United Staes within assigned regions.
2. What role does a MAC play in medical billing?
MACs handle the processing of Medicare claims submitted by healthcare providers. They verify the accuracy, coverage of each claim before the issuance of payments or denials.
3. Why is it important for providers to know their assigned MAC?
Each MAC operates differently, especially in terms of local coverage policies (LCDs) and claim submission requirements. Knowing your MAC helps in proper billing and minimizes claim denials.
4. How do MACs help reduce claim denials?
MACs provide thorough guide lines on documentation, policies of coverage, and coding standards. To provider they also offer resources to prevent common billing mistakes that often lead to denials.
5. Be a healthcare provider, can I contact MACs directly?
Yes, providers can reach out to their MAC via dedicated customer service lines and online portals for checking the status of their claims.
6. What is a Local Coverage Determination (LCD)?
An LCD is a policy issued by a MAC that defines which services are considered necessary and to be reimbursed in that specific area. Providers must follow LCDs to verify Medicare coverage and avoid denials.
7. Do MACs handle provider enrollment for Medicare?
Yes, MACs are responsible for processing new provider applications, and changes to enrollment information. They check that providers meet all requirements to obtain Medicare billing rights.
8. How medical billing company support interaction with MACs?
Medical billing companies, like MedSole RCM, help healthcare providers to stay compliant with MAC requirements by submitting clean claims, tracking denials, managing appeals, and staying up to date with policies of MAC.
Contact Us if you are Interested in learning more or getting billing support.
In today’s healthcare environment, accurate billing starts before a claim is submitted. Eligibility verification and prior authorization play an important role in minimizing claim rejections and payment delays. These steps are important because they check that patient and provider are on the same page.
In medical billing process, eligibility verification and prior authorization are very important steps. If these steps skip or not handled properly then it may lead to claim rejections, delayed reimbursements, and frustration of patients.
At MedSole RCM, we work with providers across the U.S. to handle all billing steps thoroughly and efficiently. We help practices to avoid billing issues that can impact revenue or patient care.
The process of checking insurance coverage of patient before an appointment or any procedure is the Eligibility Verification.
Things to be confirmed:
Prior authorization, also term as pre-approval or pre-certification, is when a healthcare provider must obtain approval from the insurance payer before delivering specific treatments or procedures. This is usually required for:
The insurance company have to right to delay the claim if when required prior authorization is not obtained.
With these two processes, eligibility check and prior authorization the rate of denied claims reduces, communication with patients become better, and revenue cycle improves.
Missing any of these steps can result in:
Importance of these steps can’t be denied, but these steps are time consuming too, often leads to frustrating for providers and staff. Some common hurdles include:
This is where having a medical billing partner like MedSole RCM makes a difference. Our team stays updated with payer policies and handles follow-ups, reducing errors and improving turnaround time.
Many practices now use billing platforms or clearinghouses that allow real-time eligibility checks. However, in some cases manual calls or portals check is necessary because all insurance plans are not available through automated tools.
Even with automation, human oversight is essential to:
Below are some actions by which we can reduce complications:
By setting up a clear workflow, healthcare teams can maintain better control over billing operations.
At MedSole RCM, our team handles eligibility verification and prior authorization with accuracy and consistency. We:
By this, providers can focus to deliver best patient care instead of worrying about the delays or paper work.
As we all know that Eligibility verification and prior authorization are considered to be routine tasks, but practice revenue can be directly hurt if there is a mistake in these steps. Which may result in bad patient experience.
At MedSole RCM, our team work on these processes with care and support providers by handling the entire workflow from checking coverage to managing approvals with accuracy.
Get free Consultation Today or visit our website https://medsolercm.com/
1. What is eligibility verification in medical billing?
The process of checking the status of patient’s insurance policy, whether it’s active or not, and the details of services covered by the insurance.
2. Why prior authorization is needed?
Insurance companies require prior authorization for some specific procedures or medications to confirm medical necessity before approving the payment.
3. Who is responsible for verifying eligibility and obtaining prior authorization?
Usually, the front-desk staff, billing team, or a dedicated RCM partner handles this process on behalf of providers.
4. How far in advance should eligibility be verified?
Ideally, it should be checked 24 to 72 hours before the scheduled appointment or procedure.
5. What happens if prior authorization is not obtained?
The insurance company may deny the claim, and in result of that the provider or patient financially responsible for the full cost of the service.
6. Are all procedures subject to prior authorization?
No. Only specific services listed by the insurance company require prior authorization, usually those that are costly.
7. Can prior authorization be denied even if the patient is eligible?
Yes. A patient might be eligible for coverage but still authorization be denied if the service doesn’t meet the payer’s medical necessity criteria.
8. How much time it takes to get a decision of prior authorization?
It varies payer to payer, some payers respond within 24–48 hours, while some may take up to a week. It depends on the service and documentation required.
9. If a prior authorization is denied what should provider do?
They can ask for the appeal, submit additional documentation, or request reviews with the payer's medical director.
10. Does eligibility verification guarantee payment?
Eligibility verification helps to reduce denials, but final payment depends on proper claim submission and meeting all rules of payer.
You know what’s the common challenge for medical practice now a days? Its managing collections and maintaining cash flow. From delayed reimbursements to denial rates, practices often have revenue gaps without realizing the root cause of this. This is where RCM reporting becomes a valuable asset. It not only acts as a tracking tool but will help in financial decisions of healthcare.
At MedSole RCM, we help providers turn their billing data into clear, actionable reporting. With a smart reporting system, your practice will have more control over collections, identifies patterns, and you can easily make good adjustments for steady income.
In this blog let’s discuss the real impact of RCM reporting on collections.
Revenue Cycle Management (RCM) reporting helps healthcare providers to track and interpret every stage of their financial journey from patient scheduling and charge capture to payment posting and denial management.
But beyond tracking, RCM reporting plays an important role in boosting collections and maintaining consistent cash flow.
Here’s how:
With the help of RCM reports, a practice managers can see deeply what’s working and what’s not. Reports like A/R aging, collection rates, and denial trends explains hidden delays or process gaps that affect collection and payment timeline.
This thing needs to be understood that all unpaid claims are not equal. From reports we can check the complete data that which outstanding balances are nearing timely filing limits, which require appeal, and which ones can still be collected. This prevents revenue loss from ignored follow-ups.
Denial reports help you to check patterns, for example certain billing codes or specific providers are causing more rejections or not, or insurance underpaying or not. By checking these trends early, you can take action before they affect your revenue.
Practices can easily track how quickly different payers respond, pay, or deny claims. This can help to adjust follow-up schedules and contract negotiations.
You can track with the help of reports that how much time it takes to enter charges, submit claims, or follow up. Delays in these areas directly impact cash flow and collections.
With historical data from RCM reports, you can forecast expected monthly income and identify seasonal changes making it easier to plan payroll, expansion, or equipment investments.
Different reports play different roles in managing your revenue cycle. Here are the most important ones you should review these consistently.
This report help in tracking how long payments have been outstanding broken into 30/60/90/120+ day buckets. The longer bills sit unpaid, the lower the chance of collection. This report helps your team prioritize older and high-value claims.
This report shows the reasons that why claims are being denied. Identifying top denial reasons allows you to fix issues at the source whether it's coding errors, authorization problems, or payer issues.
This report helps in tracking the percentage of billed charges being collected. A low rate is because of billing gaps, underpayments, or poor follow-up.
Measures how many claims are accepted on first submission without edits. A higher clean claim rate leads to faster payments and fewer reworks.
Calculates how many days it takes for your practice to get paid after service. Lower days in A/R means better cash flow.
Track how long it takes from patient visit to charge entry, and from claim submission to payment. Any delay can cause disturbance in cash flow.
Focuses on copay, deductible, and balance collection. These reports help improve front-desk collections and patient billing processes.
Our team at MedSole RCM doesn't just deliver billing services, we build visibility and structure into your revenue cycle through smart reporting tools.
Here’s what we provide:
Maximum collections and consistent cash flow don't happen by accident they're built on transparency, timely action, and accurate data. RCM reporting brings all of these elements together, allowing providers to manage their revenue with clarity and confidence.
Contact our Experts, we believe in giving providers the tools and support they need to make every dollar count. With the help of experts in our team, your practice can work smarter, not harder to improve collections and stabilize cash flow.
Q1: What is RCM reporting?
RCM reporting includes tracking data from various revenue cycle stages like billing, collections, and denials to understand how you manage cash flow of your practice.
Q2: How does RCM reporting improve collections?
By showing unpaid claims, denials, and aging balances, reports help to prioritize follow-up and identify gaps which are the reasons for revenue loss.
Q3: Why is cash flow important in a medical practice?
Cash flow helps in operational costs, salaries, and growth. Irregular cash flow results in financial stress and delays in patient service.
Q4: What are the most useful RCM reports?
A/R aging, denial reports, payment lag, clean claim rate, and collection performance are most important ones.
Q5: How often should I review RCM reports?
The ideal condition is that reports should be reviewed weekly and detailed summaries should be analyzed monthly.
Q6: Can RCM reports help reduce denials?
Yes, denial reports show errors or payer behaviors that can be corrected to reduce future rejections.
Q7: How does MedSole RCM support reporting?
We provide monthly and custom reports, dashboards, and hands-on support to help practices understand and make decisions based on data.
Q8: What happens if I ignore aging claims in reports?
Older claims are less likely to be paid. Ignoring aging claims results in revenue loss and missed filing deadlines.
Q9: Do small practices need RCM reporting?
Absolutely. Whether you're a solo provider or a large group, understanding your revenue cycle is key to financial health.
Q10: Where can I get help building RCM reports?
Reach out to MedSole RCM, out experts will guide you through report setup, interpretation, and improvement strategies.
In Medical billing there is a lot of things to be handle, even for experienced doctors and practice managers. With insurance rules constantly changing, new online portals for every payer, and the way reimbursements work shifting all the time. Even if you are working in healthcare for years, still you need to stay update with the billing side, because one small mistake can result in delayed payments or denied claims.
In our recent Blog we explain the importance of Eligibility verification and prior authorization, these tasks directly impact the revenue cycle. They may look similar, but there is a great difference in between the two. And misunderstanding them or skipping them may lead to major issues like claim denials, payment delays, or unexpected bills left for patient.
In this Blog, we’ll explain both terms clearly, highlight their differences, and show you how getting them right can save your practice from stress and revenue loss.
The front end of your billing process is like setting the foundation of a building. If it’s not strong, everything else suffers. That’s exactly why eligibility verification and prior authorization are two steps on which every practice should focus on.
Eligibility verification is the process of checking whether a patient’s insurance is active and what services are covered under their plan before the visit happens.
It answers key questions like:
It’s like confirming someone’s ticket before letting them into the event. If you skip this step, there’s a chance the insurance will not cover anything and the cost will be bear by provider or patient.
Prior authorization (sometimes called pre-authorization or pre-certification) is when a provider must get approval from the insurance company before delivering a service or procedure.
This is usually required for:
In simple terms, it’s like asking to insurance company that: “Can we move forward with this treatment, and will you cover it?”
|
Feature |
Eligibility Verification |
Prior Authorization |
|---|---|---|
|
Purpose |
Confirms active coverage and benefits |
Gets pre-approval for specific services or treatments |
|
When It's Done |
Before the patient visit or service |
Before the procedure or service is performed |
|
Who Does It |
Front desk, billing staff, or outsourced billing partner |
Provider’s office, billing team, or medical assistant |
|
Risk if Skipped |
Claim denial, out-of-pocket surprises for patients |
No payment from insurance even if the service was done |
At MedSole RCM, we understand that providers are already struggling alot. Checking every detail about a patient’s insurance isn’t always the top priority especially in busy clinics or practices with limited staff.
That’s where we come in.
We don’t just verify the status of insurance, whether its active or not, we dive into the details. We check:
This helps avoid surprises and gives your front desk the confidence to communicate clearly with patients.
Many procedures require prior approvals that can take days or even weeks to get. We take that burden off your team by:
This ensures that treatments will not be delay, and after providing services you don’t get stuck with denied payments.
You don’t have to spend hours checking through emails or chasing missing documents just to figure out what got approved and what didn’t. With our billing process, you can track everything clearly, from insurance verifications to authorization responses. Your team always knows what’s going on, which task is pending, and which needs follow-up. There is a clear communication and easy access to the information you need. A federal advisory body has issued recommendations that are completely aligned with the AMA’s comments and represent a major advocacy win to reduce administrative burdens and costs for physician practices. The AMA is challenging insurance companies to eliminate care delays, patient harms and practice hassles. AMA is fighting to fix prior authorization.
It’s not good for practices to skip these steps especially when the clinic is busy or the service seems routine. But here’s what happens when they don’t pay attention to these two major processes:
If a patient's insurance was inactive or the service wasn't covered, the claim will most likely be denied. That means extra work and possibly no payment.
Even if the claim is valid, still without authorization, it can be hold for weeks. That directly impacts your cash flow and staff morale.
Patients often assume their insurance will cover everything. When it doesn't, they get upset with your office, clinic or practice and may not return.
Denied claims take time to appeal. If they're not corrected in time, practices often write them off as lost revenue.
Let’s say a patient comes in for an MRI.
If any of those steps is missed, there must be a chance that you will not get paid.
Whether you’re a solo provider or running a multi-location clinic, here are a few simple ways to improve your eligibility and authorization process:
Make insurance verification part of your workflow.
Eligibility isn’t just about checking the active status of insurance but it’s about knowing what’s covered.
Don't wait until the day before the procedure. Some payers take 7–10 days.
At MedSole RCM, we handled a lot of verifications and authorizations for providers like you on time, with accuracy and consistency.
Contact Our Experts: From checking benefits to handling prior authorizations, our team guarantees you that everything is done correctly and on time so you get paid without the hassle.
No. It also involves to understand what the patient’s plan actually covers. Which means, it has to check how much of their deductible has been met, what their copay will be, the service to be delivered is included in their benefits or not, and your practice is in-network for that plan or not.
Prior authorization is required when any service, test or medication is expensive and when insurance companies want to check in detail before paying. These are not routine treatments like advanced imaging (such as MRIs), some specific surgeries, specialty medications, or ongoing therapy sessions. If you don’t get that approval in advance, there’s a chance that insurance panel will not pay for that service.
If prior authorization is not approved before providing the service, there are the chances that insurance company refuse to pay for it even if the procedure is important for the patient’s health. That means the provider could end up doing the work and not getting paid, or there might be burden on patient for the bill.
Yes, just because a patient has active insurance and is eligible under their plan doesn’t automatically mean every service will be approved. Some treatments, tests, or medications require extra steps like medical records or explanation by doctor to prove that the service is necessary. If the insurance company can deny it after review, even if the patient is covered. That’s why it's so important to provide the right documentation when requesting for prior authorization.
It mostly depends on the insurance company. Some insurances have advanced systems and can give a decision within a few hours especially for simple requests. Others may take several days or even more than that. The reason behind it if they require more paperwork, medical records, or additional reviews. The timeline can also vary based on the type of service. That’s why it’s important to start the prior authorization process as early as possible to avoid delays.
Now a days in healthcare industry Remote Patient Monitoring (RPM) has become an important component, helping providers to give services other than clinic as well. Especially for patients having serious conditions, RPM supports regular checking and better results.
Medicare recognizes the value of RPM and give reimbursement under specific guidelines. However, many healthcare professionals doing struggle to understand what Medicare covers and what are the limits. At MedSole RCM, we support practices in navigating the RPM billing process with accuracy and transparency.
This blog explains what you need to know about Medicare’s coverage of Remote Patient Monitoring (RPM), including what to bill, which devices qualify, and when claims may be denied.
The use of medical devices for collecting and transmitting of data from patients at home to healthcare providers is Remote Patient Monitoring. This process helps to get data on time and accurate for the patient’s condition.
RPM is typically used to monitor:
Medicare offers reimbursement for RPM for specific Current Procedural Terminology (CPT) codes, but the condition is that it must meet compliance and some important documentation requirements.
For Medicare reimbursement, RPM services should meet a few basic requirements:
Healthcare providers must use the following codes for billing RPM services:
Each code serves a unique purpose and requires specific documentation. Only one provider can bill RPM services for a patient in any 30-day period.
1. Setup and Education:
Covers the initial setup of the monitoring device and patient onboarding. This is billed once per episode of care.
2. Device and Transmission:
Applies when the patient uses the device for at least 16 days in a calendar month. Its mandatory to transfer data electronically without manual input.
3. Regular Monitoring:
Providers must spend more than 20 minutes to review data and communicating with the patient each month. The whole time must be tracked and documented.
4. Acute and Chronic Conditions:
RPM is not only specified for chronic illnesses. It can be used for post-operative recovery, temporary health concerns, or acute conditions if medically suitable.
5. Use in Home Settings:
The patient must be residing at home. Medicare does not cover RPM for patients in nursing facilities, in homes or long-term care centers.
Despite its benefits, RPM has limits under Medicare guidelines:
1. Manual Data Entry
Devices that require patients to manually enter results are not reimbursable. Data must be automatically recorded and transmitted.
2. Behavioral Monitoring
Tracking medication usage, mental health check-ins, and sleep patterns are not covered unless they directly relate to physiological monitoring.
3. Less Than 16 Days of Monitoring
If the patient does not meet the 16-day threshold within a month, the provider cannot bill for the device supply code.
4. Duplicate Billing
At one time only one provider or practice can bill RPM codes for a specific patient in a 30-day period.
5. Patients in facilities
Patients living in skilled nursing facilities, hospitals, or similar institutions are not eligible for RPM under Medicare rules.
As you look to bring a new level of patient care to your office by implementing remote patient monitoring (RPM), there are pitfalls you will want to avoid to ensure that you, your staff, and your patients get the most out of using this digital health solution. As AMA explains 3 missteps to avoid when implementing remote patient monitoring. MedSole RCM helps providers bill for remote monitoring programs accurately. We track and manage RPM data in line with payer guidelines. We handle the backend so you can focus on clinical outcomes. Choosing the right RPM partner has a lot of importance for maximizing revenue and improved patient outcomes. At MedSole RCM we deliver comprehensive RPM solutions from device setup and patient onboarding to billing compliance. We handle every step so you can focus on patient care.
Contact our Experts and get a free consultation for RPM services today.
1. Can we use Remote Patient Monitoring for short-term conditions?
Yes. Medicare allows RPM for both acute and chronic conditions if medically necessary.
2. Do I need to document patient consent for RPM?
Yes. Consent must be documented in the patient’s record before RPM begins.
3. How many days of data are required to bill for device usage?
At least 16 days of data must be transmitted in a 30-day period to bill 99454.
4. Can multiple providers bill RPM for the same patient?
No. Medicare only permits one provider to bill RPM per patient each month.
5. What type of devices qualify for RPM reimbursement?
Devices must automatically capture and transmit physiological data and be FDA-approved.
6. Is RPM considered a telehealth service?
No. RPM is not classified as telehealth, so it follows different billing rules.
7. Can RPM be billed with other care management services?
Yes, but time and documentation must be clearly separated for each service.
8. Is RPM covered for Medicare Advantage patients?
Most Medicare Advantage plans follow CMS guidelines, but it’s important to verify with each plan.
Managing and handling Medicare billing is a challenge that is not only about correct coding and timely submissions. The important part of this process are Medicare Administrative Contractors (MACs) entities responsible for reviewing and deciding that your claims meet the requirements for approval and reimbursement or not. For healthcare providers and billing professionals, its very important to understand how MACs operate, because it can make the difference between payment and denials.
At MedSole RCM, we recognize the importance of addressing how MACs impact claim decisions. This blog breaks down the role MACs play, what influences their approval decisions, and how providers can reduce payment delays and rejections.
A MAC is a private health insurer contracted by the Centers for Medicare & Medicaid Services (CMS) to manage the daily operations of Medicare claims. These contractors play an important role for processing of Medicare Part A and Part B claims, and are assigned by region (jurisdiction)
Their responsibilities include:
In short, MACs act as a bridge between CMS and healthcare providers to ensure proper claim handling and fund distribution. You can study our recent blog that How does MAC work in medical billing.
1. Review of Documentation and Medical Necessity
Based on Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs) MAC will check that the documents that are submitted supports medical necessity or not. Even if the claim is coded correctly, still missing or incomplete documentation may result in a denial. For instance, if a procedure is common in your specialty but it lacks specific diagnostic codes, your MAC may reject it.
2. Timeliness of Claims
MACs implement timely filing rules. Claims automatically denied if they are not submitted within the CMS allowed timeframe typically 12 months from the date of service. They also track submission patterns and may detect irregularities for review.
3. Claim Edits and Pre-Payment Reviews
MACs apply claim edits, where logic errors, missing data and incorrect or mismatched codes can be automatically check. These edits trigger rejections or requests for additional documentation. Some MACs may require pre-payment reviews for services frequently detected in audits.
4. Jurisdiction-Specific Policy Enforcement
Every MAC interprets CMS policies slightly differently. That means a claim that passes in one state may face denials in another state, based on LCD variations. Providers need to be familiar with their MAC’s jurisdictional policies and guidelines for billing that is acceptable.
1. Calculation of Allowable Charges
MACs determine allowable reimbursement amounts based on Medicare fee schedules and regional adjustments. If any service is not meeting criteria for coverage, bundling, or frequency limits, it may be reduced or denied.
2. Overpayment Requests
MACs perform post-payment reviews, which may result in overpayment findings. If a claim was paid incorrectly or lacks proper documentation, providers may be required to return the funds.
3. Delays from Technical Denials
Technical errors like incorrect NPI numbers, invalid modifiers, or missing dates may result in non-medical denials, delaying reimbursements and requiring resubmissions.
Providers with a high rate of denials or unusual billing patterns may be placed under Targeted Probe and Educate (TPE) reviews. These MAC led audits focus on providers whose claims frequently do not meet policy requirements.
MACs may request:
1. Know Your MAC Jurisdiction (region)
Each MAC has its own portal, educational materials, and contact procedures. Knowing your MAC's specific region helps in understanding its unique LCDs and communication formats.
2. Subscribe to MAC Updates
MACs publish newsletters, coding updates, and training materials. Subscribing to these updates helps your team stay updated about changes in CMS policies and claim processing rules.
3. Align Documentation with LCDs
Before billing a service, check the LCDs applicable to your MAC. These documents detail the coverage conditions and approved ICD-10 codes for common procedures.
4. Quick Response to Additional Documentation Requests (ADRs)
To prevent the automatic denials, the response should be within deadline when MACs request more information. Always include relevant and accurate documentation with your submission.
How MedSole RCM Helps You Navigate MAC Rules
Your billing partner should understand how MACs apply edits and rules to claims. At MedSole RCM, we:
Our team is familiar with MAC operations so well, that allows providers to focus on delivering best patient care. Meanwhile our team handles all administrative burden. Contact our Experts for better support.
1. What does MAC stand for?
MAC stands for Medicare Administrative Contractor; an entity contracted by CMS to process and manage Medicare claims.
2. Can a MAC deny a claim even if it’s coded correctly?
Yes. If documentation does not support medical necessity or if required elements are lack in it, MACs can deny the claim.
3. How do I know which MAC handles my claims?
You can find your MAC based on your state by visiting the CMS website or using the MAC lookup tool.
4. Does MACs same across all states?
No. MACs are assigned by jurisdiction (regions), and each has its own coverage policies (LCDs) and operational rules.
5. What is an LCD?
An LCD (Local Coverage Determination) is a policy issued by a MAC which explains about services covered and their conditions.
6. How MACs affect reimbursement amounts?
The payment calculation by MAC based on Medicare fee schedules, modifiers, and local cost factors. Errors or missing data can reduce reimbursement.
7. Do MACs provide education to providers?
Yes. MACs offer training webinars, bulletins, and instructional materials to help providers stay informed with CMS rules.
8. What triggers a MAC audit?
High denial rates, wrong billing patterns, or failure to follow coverage policies may trigger TPE or audits after payments.
9. How long does it take for a MAC to process a claim?
Processing time may vary but generally takes 14–30 days, depending on claim type and the conditions like documentation is required or not.
10. Are MACs involved in Medicare Advantage plans?
No. MACs handle traditional Medicare Part A and B claims. Medicare Advantage plans are managed by private insurers.
In recent years we have noticed that physician burnout is like one of the biggest threats for healthcare stability, its alarming also. They have to do long hours of working, manage heavy documentation, pressure of providing better services and patient satisfaction, many providers are struggling to keep up not just physically, but emotionally and mentally as well. According to the most recent study in the national burnout survey series we got to know that in 2023, 45.2% of physicians reported at least one symptom of, in 2021 it was 62.8%, 38.2% in 2020, 43.9% in 2017, 54.4% in 2014 and 45.5% in 2011. Burnout of physicians in US has improved from 2021 to 2023 and is currently at levels similar to 2017. Despite this, U.S. physicians remain at higher risk for burnout relative to other U.S. workers.
The consequences go beyond individual distress. Burnout can lead to lower patient satisfaction, staff turnover, and decreased practice performance. At MedSole RCM, we work closely with healthcare providers to reduce the pressure caused by administrative and billing work, helping physicians regain focus and energy.
But before we talk solutions, let’s talk about measurement. Because if you can’t measure it, you can’t manage it.
Physician burnout not only about feeling tired or stressed out. But it’s a long-term condition that builds up with time due to a disconnect between job demands and available resources. It often includes:
This tool is majorly used to check the three main dimensions of burnout. It gives a detailed view of how exhausted and disengaged a physician feels, and helps track changes over time.
A brief 10-question tool that focuses on job satisfaction, work pace, time spent on documentation, and EHR-related stress.
Breaks burnout into personal, work-related, and patient-related sections, making it easier to identify specific causes.
Every practice is different, and simple, anonymous surveys can help capture unique stressors and system inefficiencies affecting your physicians.
Increase in absentees or turnover is often a red flag. Practices can easily monitor these indirect metrics to identify burnout trends.
How MedSole RCM Helps Address Physician Burnout
Reducing burnout requires more than wellness workshops, it demands practical relief from the daily grind. One of the leading causes of stress is the administrative load physicians carry. With endless documentation, coding, billing issues, and back-and-forth with payers, many doctors spend more time on paperwork than patient care.
We handle your claims submission, denial management, and payment follow-ups so your providers can focus on care—not paperwork.
Credentialing delays and re-submissions take up time and mental space. We handle these tasks efficiently to eliminate distractions from clinical work.
We provide timely, readable revenue cycle updates so physicians don’t have to chase financial clarity.
By reducing billing issues, claim resubmissions, and AR backlogs, we help your medical office, and it will function more smoothly.
Our team works with your staff to implement billing strategies that ease the workflow and save time. No more late-night paperwork or claim status checks.
When physicians are less burdened by administrative work, they:
There is no situation that can be solve overnight, so is burnout, but making smart operational changes like partnering with a billing company like MedSole RCM can significantly make you feel relaxed.
Physician burnout is not only a word, it’s a growing concern that requires practical solutions. You don’t need to change your entire system to make a difference. You can easily start with what you can control: reduce the overload. Let MedSole RCM support your team by handling the backend work, so your physicians can breathe easier, perform better, and stay longer in the profession they love.
Contact Our Experts to get billing support and make your staff to perform their duties better.
Claim denials are one of the most regular challenges in medical billing. Whether it's a missing modifier, incorrect code, or expired insurance, every denial delay revenue and creates extra work for providers and billing teams. In fact, the American Medical Association reports that nearly 10% of all claims submitted to payers are denied upon first submission.
At MedSole RCM, we’ve learned that most denials are avoidable with a proactive approach. This blog breaks down the top 20 reasons claims are denied and shows how effective denial management can turn those rejections into recoverable revenue.
Each denied claim adds labor hours, delays payments, and risks never being reimbursed. On average, it costs $25–$100 to rework a denied claim, and up to 65% of practices simply write them off due to lack of resources. That’s why a denial isn’t just a rejection it’s a red flag that must be addressed immediately.
Denial management is not just about fixing rejected claims but it's about preventing them in the first place. It involves tracking denial trends, analyzing root causes, and applying real-time corrections throughout the billing cycle.
Hospitals and health systems have been challenged by lower collection rates and high denials from insured patients, which created financial headwinds. Below are the top 20 reasons claims are denied along with how denial management processes can resolve and prevent them.
At MedSole RCM, we follow a structured denial management workflow:
Claim denials not only impact your practice cash flow, but they also give you a chance to improve how your billing works. When you and your team understand the reasons behind denied claims, you will fix those issues and use strategies to stop them from happening again. By the help of good denial management system, you not only avoid future mistakes but also recover lost revenue.
The Expert at MedSole RCM use the right tools, knowledge, and continuous efforts to turn denied claims into approved payments. With our approach you can improve your overall billing process and we keep your revenue cycle moving smoothly.
Q. What is a claim denial in medical billing?
A claim denial happens if an insurance company decide that they will not pay for a service because of mistakes, missing details, or problems with the patient’s insurance policy.
Q. How is a denial different from a rejection?
Rejections occur before the claim is accepted into the payer’s system, while denials happen after the claim has been processed and evaluated.
Q. What is denial management?
Denial management means finding out the reason, why claims were denied, then fixing the issues, sending them again if required, and use strategies to improve the process to avoid future denials.
Q. Can denied claims be corrected and resubmitted?
Yes, most denied claims can be corrected and resubmitted if done within the payer’s time limits.
Q. What is the time limit to appeal a denial?
Each insurance panel has different timeframes, varies in between 30 to 180 days from the date of denial.
Q. How often should denial trends be reviewed?
Monthly trend analysis is recommended to catch recurring issues early.
Q. What are common preventable denials?
Examples include incorrect patient info, authorization issues, and coding mismatches.
Q. How does MedSole RCM reduce denial rates?
Our Experts will keep an eye on every claim, fix the mistakes right away, appeal the denied claims, and teaching staff how to handle common problems.
In today’s complex healthcare environment, practices face significant challenges in managing revenue cycle operations. That's where a top medical billing company like MedSole RCM becomes invaluable. We bring deeper experience, advanced systems, and more refined processes that go far beyond basic claim submission. But what exactly makes the best stand out in the industry?
At MedSole RCM, we’ve studied what high-performing billing partners do differently and how those approaches benefit practices of all sizes. This blog explores the key differentiators that elevate top billing companies in the USA, helping providers reduce errors, boost revenue, and maintain compliance.
Leading firms don’t simply submit claims; they closely monitor rejections and denials, identify root causes, and implement corrective action plans. As we are doing this at MedSole RCM by deploying denial management services, we reduce write-offs and recover lost revenue faster than competitors. Practices gain clear reporting and transparency at each stage.
The leading and high performing companies use data tracking and reporting to monitor every part of the revenue cycle from patient registration and charge entry to AR aging and payment posting. Revenue cycle analytics uncover hidden issues and support decision-making for better financial outcomes.
By maintaining established insurance payer relations, like top billing firms MedSole RCM can resolve claim issues faster and gain direct lines of communication with carrier reps. These relationships speed resolution and reduce denials tied to misunderstandings or delays.
Accurate coding and compliance with federal billing regulations are essential. The best billing groups employ certified coders who stay current with CPT, HCPCS, and ICD‑10 updates. Our billing compliance strategy includes regular internal audits to prevent denials and audits.
Top medical billing companies use advanced tools like electronic remittance advice (ERA) systems and payer scrubbers to improve their billing process. At MedSole RCM these tools help us to detect mistakes at early stage, double-check the information, and speed up the time it takes for insurance companies to process claims. When a company has a strong system for checking claims, it lowers the chances of human mistakes and then payments are made faster and more accurately.
Top companies provide clients with real-time dashboards, weekly updates, and summary reports. When we offer transparency to clients, it builds confidence in the billing operation and makes it easier to assess performance.
Handling areas like RCM for behavioral health, DME, or telehealth requires unique coding knowledge and payer guidelines. Specialized billing support ensures practices in niche fields don’t suffer from improper coding or policy misalignment.
Rather than automating every task, top firms assign experienced teams to manage aged receivables. These specialists focus on high-value accounts and helps to increase cash flow.
Leading companies hold regular training sessions for their team and often for client staff, covering payer trends, documentation expectations, and regulatory shifts. Proactive education keeps everyone aligned.
Below, we dive deeper into core strategies that define success:
Data-Driven Denial Resolution: Top billing companies analyze denial trends monthly to identify patterns whether by code, provider, payer, or location. This insight allows them to adjust workflows, train providers, or upgrade systems as needed.
Quality Control in Charge Entry: By implementing double-review workflows and automated scrubbing tools, the best maintains high claim processing accuracy. Their internal compliance teams support error detection before claims are submitted.
Credentialing Support: Enrollment errors cause many denials. The top companies ensure providers are enrolled, PTANs validated, and recredentialed before billing roles.
Appeals and Escalations: Some billing companies treat denied claims as lost. Top firms view them as opportunities, building appeals, reframing documentation, and escalating when necessary to recoup revenue.
Custom Workflow Implementation: While avoiding certain marketing terms, a high-level service-based approach means creating practice-specific workflows that align with provider needs, specialties, and payer mix.
Performance Benchmarking: The best benchmark against national KPIs, denial % rates, AR days, net collection rates, allowing providers to measure their billing function against peers.
|
Feature |
Impact on Practice |
|---|---|
|
Denial management services |
Recovers more revenue, reduces administrative burden |
|
Revenue analytics |
Enables data-backed improvement decisions |
|
Payer relationships |
Manages claim resolution |
|
Coding & compliance strategy |
Reduces audits, ensures legal billing |
|
Claim processing accuracy |
Improves reimbursement speed |
|
AR management teams |
Frees up provider time, accelerates cash flow |
|
Practice-specific adaption |
Works well across specialties and sizes |
|
Benchmarking |
Highlights performance potential |
At MedSole RCM, our mission is helping practices function at peak capacity. Here's how we apply these differentiators:
Choosing a top medical billing company isn’t just about outsourcing your claims but it’s about partnering with an organization that actively strengthens your revenue cycle, reduces risk, and supports long‑term growth. From denial management to payer relations and analytics, these leaders offer specialized services that translate to better cash flow, fewer headaches, and sustained trust.
Contact our Experts, we bring all of these elements together, guarantees you that your practice never misses a dollar.
Private medical practices face increasing financial pressure, from rising operational costs to shrinking reimbursement margins. Effective RCM Solutions (Revenue Cycle Management) play a major role in a practice’s financial health, and outsourcing that area has become a strategic decision for growing or even developed practices.
When you outsource trusted RCM partner, you will have an access to experienced teams, advanced technology, and revenue-focused workflows. What will be the results then? Faster payments, fewer errors, and a better bottom line. In this post, we explore the specific financial benefits of outsourcing RCM Solutions, backed by insights from MedSole RCM.
Managing in-house billing means paying for staff salaries, benefits, training, licensing, and software maintenance. Outsourced RCM replaces those with predictable monthly fees, a revenue cycle outsourcing model that usually costs less per claim.
RCM providers manage claims processing efficiency through faster submission, denial tracking, and AR follow-up. If claims are processed without delay, then practices will get faster reimbursements and cash flow increases.
We know that if the claim denials are regular then it will waste time and money. Outsourced RCM teams use particular denial management tools, real-time payer insights, and root-cause analytics to reduce errors. That saves the time of staff and improves net collections.
RCM companies invest in the latest billing platforms, payer connectivity, scrubbing tools, and reporting dashboards. Practices get those capabilities without software purchase or update costs.
Different practices have different needs and requirements, whether you are running mental health clinic, orthopedic group, or multi-provider practice, medical billing ROI increases if your practice is handled by specialists who understand insurance requirements and documentation rules.
Fluctuating billing performance causes uncertainty. Outsourcing the RCM creates a predictable revenue stream based on contracts, increase cash flow forecasting and budgeting.
Regulatory audits and payer overpayment recoupments are costly. Dedicated RCM providers monitor compliance changes, audit internally, and prevent billing mistakes that attract scrutiny.
With consistent follow-up, claim submissions, and claims denial management, AR days can be reduced by 20–40%. That accelerates collections and eases cash flow issues.
Practices often achieve 95–98% of gross charge capture. Outsourced RCM providers help by ensuring all claims are billed, corrected, and successfully paid, maximizing your revenue.
Outsourcing means you don’t have any need to recruit billing staff, train, and manage. This ultimately cuts costs for human resources, management time, office space, and software licenses.
RCM providers apply standardized workflows across all practices they serve. That consistency improves claim volume business predictability and accounting clarity.
By handling insurance verification, organizations eliminate wrong payer denials and surprises later in the billing process.
Dedicated billers ensure dates, codes, modifiers, and documentation align with payer rules, results in less resubmissions.
A full focus on denial tracking, root-cause corrections, and resubmission adds measurable revenue previously lost in-house.
Automated scrubbing tools flag errors before submission, dramatically reducing rej ections and cleaning up claims.
RCM Solutions include AR specialists who escalate unpaid claims, prepare appeals, and contact payers on your behalf.
The major revenue cycle metrics like denial percentage, AR days, net collection and payer performance can be tracked by custom dashboards.
A multi-provider clinic partnered with MedSole RCM. After six months, results included:
The practice achieved high ROI and reinvested savings in growth rather than overhead cost.
1. Easy to Scale with Your Workload:
Private practices have simple solutions, outsource their Revenue Cycle Management (RCM), they gain access to a team that can perform according to the practice’s needs. If patient volume increases or decreases, the outsourced team can quickly grow or reduce support without the clinic having to hire or fire staff. This makes it easier to manage busy seasons or handle growth without any delays or stress.
2. Access to Specialized Knowledge:
RCM companies work with many types of healthcare providers and insurance payers every day. They have deep knowledge of billing rules and regulations, claim codes, and industry trends. This helps private practices to avoid common mistakes and get benefit from the best billing strategies.
3. Less Administrative Work for Doctors:
By outsourcing billing and other tasks, doctors and their in-house teams will no longer need to chase payments. They don’t have to spend time in fixing claim errors, or staying updated with insurance changes.
4. Transparent Reporting and Better Decision-Making:
RCM service providers offer detailed and easy-to-understand reports about billing performance, revenue graph, and unpaid claims. These reports help clinic owners and managers to see clearly how the business is doing and they can make smart decisions to improve financial health.
Outsourcing RCM Solutions is more than a convenience, it's a financial strategy. Private practices gain faster payments, fewer errors, and reduced costs, all contributing to healthier margins and growth.
At MedSole RCM, we partner with private practices to manage every aspect of billing, helps in revenue recovery, and enhance financial performance. Contact our Experts for better advice.
In today’s healthcare industry, almost every practice face challenges for growing especially hospitals, they have to focus on boosting revenue and manage administrative burden efficiently. Any error in billing, delay in claim processing and denials can impact a hospitals revenue. Here is the point where is the need of outsourcing Revenue Cycle Management. And hospitals that are having external RCM partners often have better collections, improve cash flow, and less billing issues.
This blog will break down how outsourcing RCM services benefits hospitals financially. We'll also explore how effective these partnerships in improving workflow and reducing operational stress.
RCM, or Revenue Cycle Management, is the administrative and financial processes used to track patient care from patient registration to final payment. RCM for Hospitals includes:
These tasks require constant attention and experienced staff. It will result in losing revenue and compliance issues, if not managed properly.
Outsourcing RCM services can reduce internal overhead, improve claim turnaround, and drive consistent revenue flow. Hospitals and health systems have been challenged by lower collection rates from insured patients and higher initial denial rates. Let’s explore the key financial benefits in detail:
Managing a full-time billing department in a hospital is expensive. It includes salaries, benefits, training, and technology. By outsourcing, hospitals shift these costs to the RCM provider and only pay for services rendered.
RCM companies focus exclusively on billing. They are focused on checking coding errors, eligibility issues, or incomplete claim before submission. By doing this, these companies save hospitals from doing work again, denials and delay in payments.
The expert RCM partners can do follow up on claims quickly, submit the claims on first try and handles the denials very effectively. This may result in faster reimbursements and keeping good revenue flow.
The outsource RCM teams normally use the best claim scrubbing tools and they are always stay updated with insurance rules and regulations, it results in less denials that cost hospitals time and money to reprocess.
Hospitals have a large volume of patients. An outsourced RCM partner helps them to manage large volumes of patients without hiring new staff or downsizing, and also keep billing up-to-date.
RCM firms often use advanced billing and analytics platforms. By having partnership with RCM team hospitals can get benefit from these tools without the burden of buying and maintaining expensive software.
External RCM partners offer detailed reports that help hospital administrators to understand performance metrics like Days in A/R, denial trends, and collection rates. This insight results in better revenue forecasting and planning.
By outsourcing administrative tasks, the hospitals staff will have more focus on patient care and less on back-office operations.
Hospitals can rely on RCM partners to stay up-to-date with insurance rules and regulatory guidelines. This lowers the risk of audit and ultimately protects revenue.
Maintaining an in-house system is very expensive, the cost from billing software to secure communication tools, all is high. Outsourcing can reduce this burden and ensures hospitals use updated systems without large expenses.
Hospitals working with better RCM providers mostly experience fewer revenue surprises. Their financial statements become more predictable, which results in better budgeting and investment decisions.
Insurance rules vary from state to state, their plan is different, and even procedure. An experienced RCM partner check this complexity, and reduce the number of underpaid or unpaid claims.
Outsource teams implement tracking system to identify trends and resolve the root cause of the denials to handle it effectively, which results in saving the lost revenue of the hospitals.
Hospitals can choose payment models such as per-claim, percentage of collections, or fixed monthly fees—helping them control and predict their RCM expenses.
If internal billing staff resign or go on leave, revenue collection can slow down. RCM partners provide continuity and avoid workflow disruptions.
Billing errors and delays in process or anything can frustrate patients. A smoother and accurate billing experience with less errors creates a more professional image of hospital and enhances patient trust.
Hospitals face a lot of challenges, from delay in reimbursements to shortages of staff. Partnering with a capable RCM services provider reduces financial pressure and helps hospitals to operate more efficiently. Outsourcing RCM is not only a cost-saving measure; it’s a long-term strategy to boost revenue, compliance, and improve the overall financial health of hospitals.
Contact MedSole RCM, because the team is committed to helping hospitals grow stronger with results-driven billing support.
Healthcare services are going through big changes, especially in the rural parts of Arizona. Clinics in these areas are having more paperwork, strict rules and regulations, and less resources to manage their daily operations. Because of this, many rural clinics are now making important decisions to keep their finances healthy so that they will maintain focus on patient care.
Outsourcing medical billing operations has become major trend in 2025. For multiple operational tasks like claim management, medical coding, and communication with insurance panels the clinics mostly working with outside companies. This helps them reduce pressure on their staff and gives them access to professional billing support that can impact positively on their reimbursement. The clinics those are facing shortage of staff, outdated systems, or delays in revenue, the outsourcing billing to a Medical Billing Company in Arizona is now a necessity.
Rural clinics have very different environment as compared to urban healthcare centers. They mostly serve less patients, are more spread out, and having lack of access to advanced resources. Arizona, with its vast deserts and isolated towns, has many clinics that struggle with basic healthcare logistics, billing being one of the most demanding.
The smaller number of staff in administration is one of the major issue these clinics are facing. Most of them are not able to afford a full team of billing specialists who can updated them with insurance regulations and reimbursement rules. In such cases, the in-house teams mostly have to do multiple tasks, for example they have to handle front-desk operations, insurance verification, coding, and follow-up. The load of work leads to billing errors, loss in revenue, and increasing burnout among staff.
Another major issue is technology. Many rural clinics still using an old system that are not compatible with modern billing platforms or electronic health records (EHRs). This may result in delayed reimbursements. Moreover, the IT support is required for maintaining or upgrading the billing software, which is not always available or affordable in rural locations.
These hindrances result in high denial rates and longer reimbursement cycles. In a state like Arizona where Medicaid expansion and insurance having a lot of complexity, many clinics then find it difficult to maintain a healthy cash flow.
The year 2025 has become a turning point for rural clinics in Arizona for multiple reasons. First, the COVID-19 pandemic results in multiple weaknesses of system in healthcare billing, particularly for small and rural practices. Providers has to assess the operational strategies and focusing on financial sustainability.
Second, the Centers for Medicare & Medicaid Services (CMS) has been rolling out updates to billing codes, reimbursement structures, and compliance requirements. The in-house staff need to learn these new updates, which is adding more work load.
Third, inflation and cost-of-living increases have made it difficult to retain billing staff. Many clinics were losing experienced staff members who moved to larger organizations or chosen remote billing roles with better pay. As a result, outsourcing medical billing partner is a wise decision.
Finally, advancements in technology results in easier outsourcing. Cloud-based systems allow billing partners to work remotely and securely. This connectivity has opened new avenues for clinics in remote towns to partner with reliable medical billing companies in Arizona.
The major benefit of outsourcing is having access to most experienced billing professionals. These specialists handle everything of your practice, from coding to denial management, giving the clinic’s internal team to focus more on patient services and satisfaction.
With outsourcing, clinics often see faster claim processing. Dedicated billing teams work with clearinghouses and insurance panels to reduce turnaround time. This helps in improving cash flow and allows better visibility of revenue cycle to leadership.
Outsourcing also helps with payer communication. Billing companies have direct contacts and better insight into specific insurance requirements in Arizona, results in less rejections.
Additionally, an outsourced billing company provides such kind of tools for reporting that show real-time data on collections, claim status, and patient balances. For rural clinics this financial visibility can supports better planning and decision-making.
As rural clinics continue to grow their patient base through telehealth and urgent care services, having a flexible billing partner also allows them to scale without adding internal headcount or infrastructure.
How Arizona-Based Billing Companies Are Supporting Rural Clinics
Local companies like MedSole RCM understand the specific challenges of Arizona's healthcare environment. This includes the payer landscape (such as AHCCCS), regional patient demographics, and access barriers. Unlike national billing firms, local partners are more familiar with state-specific nuances.
For instance, knowing how to bill services under Arizona’s Medicaid programs or how to navigate telehealth codes that vary from county to county is essential. A Medical Billing Company in Arizona can align services more closely with what rural providers need. Also, billing partners offer more accessible customer support.
There is a long-term financial benefit of outsourcing for rural clinics. When denial rates go down, payments come in quicker. When patient statements are clear and timely, collections improve. When follow-ups are consistent, aging AR reduces.
If they outsource the operational work, then providers can spend more time for delivering best patient care and services instead of correcting clerical errors. This can ultimately build the community trust. For many rural healthcare professionals, this is the most meaningful return on investment.
Also, outsourced billing partners offer performance-based pricing models. This reduces the risk associated with hiring, training, and retaining billing staff internally.
As shared by the National Rural Health Association (NRHA) in a report on rural revenue cycle management, outsourcing billing was listed among the top strategies for rural financial resilience.
When selecting a billing partner, rural clinics should focus on transparency, experience with Arizona insurances, and responsive support. It’s important to ask about turnaround times, rejection follow-up protocols, and reporting capabilities.
Trust is also key. Outsourcing requires sharing sensitive financial and patient data. Make sure the billing partner adheres to HIPAA standards and uses secure technologies.
Contact our experts because MedSole RCM works with several clinics in Arizona’s rural areas, offering flexible billing services and local expertise. Our team understands the practical challenges that are faced by small clinics and supports them with better and consistent results, not false promises.
Why are rural clinics outsourcing their billing in 2025?
Rular clinics prefer to outsource their billing because of some reasons like shortage of staff, increase in claim complexity, and financial pressure. So, many rural clinics are outsourcing billing to reduce errors and to increase reimbursements.
Is outsourcing billing secure for rural clinics?
Yes. The major reputable medical billing companies follow HIPAA rules and regulations and use encrypted platforms to protect patient and financial data. Because security is the main concern.
Does billing errors reduced by outsourcing the billing?
Yes. If the billing professionals are experienced then they mostly use modern tools and insurance-specific knowledge to submit claims accurately and results in fewer denials.
How does outsourcing affect cash flow?
Outsourcing typically results in faster claim submission and denial management, which ultimately helps clinics to get reimbursements more quickly.
Are there local billing companies in Arizona that specialize in rural clinics?
Yes. MedSole RCM is one example of a local billing partner with experience supporting rural clinics across Arizona.
What are the costs involved in outsourcing?
Most companies charge a percentage of collections, which aligns their earnings with clinic revenue. This makes it a flexible option for smaller practices.
Do billing companies help with payer credentialing?
Many do. While not all offer credentialing, companies like MedSole RCM help providers in managing insurance enrollment and renewals.
How do I get started with outsourcing my billing?
Reach out to a local provider like MedSole RCM. They typically begin with a consultation, audit your current billing setup, and offer a proposal based on your clinic’s needs.
Our team provides eligibility verification and prior authorization services with accuracy and consistency. We work directly with payers to confirm benefit details and initiate approval requests for procedures that require it. This minimizes the claim resubmissions and helps practices to reduce the disputes of billing.
We understand that insurance verification and authorization consume a lot of time of front-desk staff. That’s where we step in, taking care of billing tasks and providers focus more on patient care instead of administrative complexities.
Small clinics often lack the bandwidth to keep up with changing payer rules. Yet, they are not exempt from facing denials for missing or inaccurate authorization steps. Our insurance authorization and verification services ensure that even the most resource-limited clinics stay on top of their billing workflow.
Whether your clinic sees ten patients or a hundred, the same rules apply. Verifying each patient’s coverage and obtaining prior approval for certain services makes a tangible difference in how quickly you get paid.
The term benefits investigation vs prior authorization is often misunderstood. A benefits investigation involves identifying what a patient’s insurance plan will pay for. It’s similar to eligibility verification but includes a more in-depth analysis of plan benefits specific to the service.
Prior authorization, on the other hand, is the payer’s permission to proceed with a medical service. The two work hand-in-hand. Without a proper benefits investigation, prior authorization might be delayed or denied, especially if the request doesn’t match what the insurance actually covers.
Understanding the benefits investigation vs prior authorization difference can help reduce rework and ensure your patients receive care without administrative delays.
As healthcare technology grows, and also the payer requirements. Many insurance companies are now implementing the new rules of prior authorization processes, and more complex portals. As a result of this the front-desk can face more pressure, who already manage scheduling, eligibility, and financial counseling.
Inaccurate insurance verification and authorization causes:
MedSole RCM addresses these issues head-on by offering insurance authorization and verification services that reduce errors and save time.
In 2025, real-time data access is more important than ever. Our systems are designed to provide real-time verification and prior authorization updates, It helps your staff to get the responses more quickly and in less time.
We integrate with payer portals, clearinghouses, and electronic health records to keep data up to date. This not only speeds up eligibility checks but also guarnatees that authorizations are submitted with all necessary documentation.
Our approach to eligibility verification and prior authorization services is focused on precision and follow-through. We:
This helps practices improve clean claim rates and reduce patient disputes related to denied coverage.
Clinics across Arizona and Texas are increasingly relying on insurance authorization and verification services to handle the complexity of payer policies.
A report by the American Medical Association in 2024 found that nearly 90% of physicians said prior authorizations sometimes delay patient care. Read the AMA report here.
Delays in prior authorizations often translate into revenue delays for the clinic. That’s why outsourcing eligibility verification and prior authorization services to dedicated billing teams is proving effective in reducing denials and accelerating payments.
We also help educate your team on the difference between eligibility verification and prior authorization to ensure consistency across your front desk, billing, and scheduling teams.
We provide:
By clarifying benefits investigation vs prior authorization, the unnecessary resubmissions can be avoid by your team, and they will communicate more effectively with patients about coverage and responsibilities.
If the complexities are growing in insurance billing, it means practices should be proactive. Ignoring the importance of eligibility verification and prior authorization can lead to financial losses, poor patient experiences, and administrative stress.
MedSole RCM’s eligibility verification and prior authorization services are designed to give your clinic a stronger foundation for every patient encounter. Whether you’re looking to understand the difference between eligibility verification and prior authorization or need help handling insurance verification and authorization in bulk, we’re here to support you.
What’s the difference between eligibility verification and prior authorization?
Eligibility verification confirms about coverage. And prior authorization confirms that the procedure or treatment is approved for payment or not.
Are both eligibility verification and prior authorization necessary for every patient?
Not always. Eligibility verification is needed for every patient visit. Prior authorization is only required for certain services.
How long does prior authorization take?
It can range from a few hours to several days depending on the payer and type of service.
Who is responsible for getting prior authorization?
Typically, the provider or their billing team (like MedSole RCM) is responsible.
What happens if prior authorization is not obtained?
The insurance may deny the claim, and the patient could be held financially responsible.
How does MedSole RCM assist with insurance verification and authorization?
We verify insurance details, identify authorization requirements, and follow up with payers for approvals.
What is a benefits investigation vs prior authorization?
A benefits investigation checks coverage terms. Prior authorization is the process of securing approval for services.
Do prior authorizations expire?
Yes, most approvals are valid for a limited time or a set number of visits.
Can you appeal a denied prior authorization?
Yes. MedSole RCM helps clinics appeal denials and submit additional documentation if needed.
Are insurance authorization and verification services available for small clinics?
Absolutely. Our services are designed to support practices of all sizes.
How often do payer rules for prior authorization change?
Frequently. That’s why having a partner like MedSole RCM helps you stay current.
Can prior authorization be done electronically?
Yes, many payers support electronic submissions, which we use to speed up the process.
In the era of evolving U.S. healthcare, remote patient monitoring Medicare services are transforming that how care is delivered and reimbursed. At MedSole RCM, we’ve seen a regular increase in interest among providers to adopt RPM Medicare solutions not only for patient care but also to create an additional revenue stream. We can say that the success of any program depends on understanding remote patient monitoring guidelines, proper documentation, and regular claim submission practices.
Providers who are new to Medicare remote patient monitoring mostly ask question, "Does Medicare cover remote patient monitoring?" The answer is yes, but there are some conditions and documentation requirements that should be met for proper reimbursement.
Remote Patient Monitoring (RPM) is about the collection and analysis of patients’ physiological data outside traditional healthcare settings, typically using digital devices. It allows healthcare providers to track some metrics like blood pressure, glucose levels, oxygen saturation, and more without having a patient in clinic.
This model of care is expanding day by day, especially under Medicare remote patient monitoring initiatives. CMS (Centers for Medicare & Medicaid Services) recognized RPM as an important tool for improving patient care and reducing hospital readmissions.
Yes. Medicare covers remote patient monitoring under specific CPT codes (e.g., 99453, 99454, 99457, and 99458). However, this coverage requires:
Providers must also align with remote patient monitoring documentation requirements to get reimbursed. This includes detailed reports on time spent, patient data summaries, and billing logs.
Many providers face denials due to improper documentation, wrong usage of CPT codes, or misunderstanding remote patient monitoring billing guidelines. Our team at MedSole RCM reviews:
By correcting these issues, our clients have seen cleaner claims and faster payments.
Proper documentation is the backbone of successful RPM billing. CMS has specific expectations on how the data must be collected, recorded, and reported:
Failing to meet these thresholds may results in audits or lead to denials. MedSole RCM ensures that these documentation points are met, every time.
CMS updates remote patient monitoring regulations regularly. Some rules include:
MedSole RCM continuously tracks MS guidelines for remote patient monitoring to help providers stay compliant with the most current rules. Learn more about CMS’s official RPM rules.
Following remote patient monitoring guidelines improves revenue potential, reduces no-shows, and strengthens patient adherence. It also allows practices to:
With our experience managing remote patient monitoring billing for several specialties, MedSole RCM helps healthcare providers take full advantage of this opportunity.
We’ve helped clinics scale their Medicare remote patient monitoring programs from scratch. Whether it’s creating audit-proof documentation or dealing with billing complexities, MedSole RCM offers clarity and actionable solutions. We not only handle your billing; but we assure you that your RPM program is measurable, and compliant with every payer’s expectation.
We manage yoyr revenue and keep it on increasing, providing you real-time updates to remote patient monitoring guidelines, and your claims are always aligned with CMS’s billing logic.
RPM stands for Remote Patient Monitoring, and Medicare can reimburse to providers for managing patients’ health data remotely.
Patient consent, time logs, device data reports, and management notes.
Yes, especially for chronic conditions like hypertension, diabetes, or COPD.
These include device standards, patient eligibility, and proper CPT usage.
Yes. Data must be collected for at least 16 days in a 30-day period to bill.
Some do, but many have their own billing policies.
Claims may be denied. That’s why documentation is key.
We assist with CPT code assignment, documentation, payer portal submission, and denial follow-ups.
Usually yearly through CMS’s final rule publications.
No. Only FDA-cleared medical-grade devices that collect physiological data qualify.
Yes, with proper separation of services and documentation.
It can take 1–3 months depending on device setup and patient onboarding.
Depends on the number of services rendered monthly but can range from $100 to $200 per patient per month.
Contact our Experts. MedSole RCM continues to help providers grow their revenue and compliance by mastering the fine details of remote patient monitoring billing
AS we all know that Mental health awareness is rising across the whole United States, and along with this, the demand for behavioral health services increases. In America, we have seen that people who are suffering from anxiety, depression, trauma, addiction, and PTSD are seeking help. So many therapists, counselors or psychiatrist take a logical step of opening a behavioral health practice. But before launching, it’s mandatory to understand the real challenges to sustain such a practice.
Whether you’re a licensed psychologist or a recent graduate entering the field, this blog will help you to understand the reality of starting and managing a behavioral health practice in the U.S.
Before opening the practice, every therapist needs to understand that that license is more important, to start the practice in any particular state to provide services legally. Each state has different requirements for providers like social workers, therapists, counselors, and psychologists.
They also have to choose a business structure like LLC, PLLC, or a corporation, all depending on state's rules and long-term goals of providers. Many behavioral health professionals start as solo practitioners and after some time expand to group practices.
The main process is credentialing, which means enrolling with insurance companies so you can bill them for your provided services. It’s not quick, it may take 90–180 days. Credentialing for therapists involves collecting licensure documents, proof of malpractice insurance, education history, and much more.
If you're not credentialed, you’ll either have to collect cash payments or use superbills and both of them not having a long-term sustainability. Insurance paneling for behavioral health providers allows access to a broader patient base.
Start the credentialing process at least three months before giving your services. Partnering with a medical billing company like MedSole RCM can help manage credentialing in time.
Behavioral health billing is unlike standard medical billing. You’ll need to understand:
Incorrect coding may result in denials, delayed payments, or audits.
Electronic Medical Records (EMRs) designed for general practitioners don’t always support behavioral health workflows. You’ll need a platform that supports:
Some popular EMRs for behavioral health include SimplePractice, TherapyNotes, and Valant.
Here’s what every provider should cover before opening:
Skipping any step may results in delay in your launch or you will face billing headaches.
New practices often struggle to get clients in the first few months. You can build referral sources by:
Word of mouth is powerful in behavioral health, but it takes time to build.
Going in-network means lower rates but higher patient volume. Out-of-network lets you set your rates but limits accessibility. Many new providers go in-network to build a caseload, then shift partially out-of-network later.
Make this decision early and structure your billing model around it.
Even with proper credentialing and accurate billing, denials happen. Common reasons include:
Partnering with denial management experts can save months of delayed income. At MedSole RCM, we’ve helped practices recover from 50% denial rates to clean claims in under 90 days.
As your caseload grows, you may want to hire:
Vet staff thoroughly. In behavioral health, the provider-patient relationship is delicate—adding the wrong clinician or assistant can hurt your brand.
If you’re offering virtual services or telehealth assistance, you must follow telehealth laws in each state where your clients reside. This includes licensure, documentation, and consent protocols.
As of 2025, Medicare and many private insurers cover behavioral telehealth, but rules vary.
New behavioral health practices often take 3–6 months before they reach financial consistency. Expect the following:
You’ll want at least 3 months of operating expenses saved or a part-time income source while building.
Having a billing partner that knows the behavioral health landscape can prevent many of the early-stage problems:
At MedSole RCM, we support solo practitioners and growing group practices. Our team handles all like credentialing, billing, and follow-ups, so you can maintain your focus on patient care.
No doubt that opening a behavioral health practice in the USA is very rewarding, but it has a lot of real operational challenges. For example, credentialing hurdles, billing complexities, telehealth compliance and client outreach, each and every step requires planning and strategy.
When providers pay attention to the administrative side as much as they are focusing on the clinical side, they can grow faster and serve better.
It takes around 90 to 180 days, depending on the insurance and state.
Yes, as out-of-network or cash-pay, but clients may not get reimbursement.
Yes, it’s required by most insurers and licensing boards.
Yes, it is different, a business license allows you to legally operate in your city or county.
Popular choices include TherapyNotes, SimplePractice, and Valant.
It depends on your volume. Many solo providers do better with expert help.
An LLC or PLLC is generally preferred for liability protection.
Only if licensed in both states or if your state participates in PSYPACT.
Work with a credentialing service or billing partner familiar with your payer mix.
Yes, it’s a central database most payers use for credentialing.
Yes, but let them know they may not be reimbursed.
Varies, but 5–10 is a reasonable start if marketing is active.
Delaying credentialing or trying to handle billing alone.
The process of sending a healthcare provider's claims to an insurance company or government program by using digital methods instead of paper forms, to get reimbursement and reduce reimbursement delays for medical services that has been provided to patients, this process is actually the electronic claim submission. This step of insurance claims is the important part of the medical billing process in healthcare and requires proper precision to avoid rejections, delays, or denials.
Each insurance claim includes patient details, procedure codes, diagnosis codes, charges, and the detail credentials of healthcare providers. To submit claims with accuracy and on time can significantly can definitely impact a financial stability of healthcare providers. If claims are submitted efficiently and accurately, it will be the success of the billing operations of any practice.
Accuracy and timing can be the difference between fast payments and delay in revenue. An incorrect claim submission can result in denials or rejections in medical billing process, may leading to revenue loss. Timely submissions also align with payer-specific deadlines. Missing those deadlines often results in outright rejections that can’t be refiled.
MedSole RCM ensures that each insurance claim meets the payer’s format, coding, and documentation standards. By focusing on the resolution rate, we reduce the need for resubmissions and appeals. This focus not only reduce the payment cycle and increases efficiency of medical billing process but also minimizes the administrative workload.
Insurance Claims can be rejected or denied even due to minor errors. Below are the most common mistakes seen during the claim submission process:
Each error disrupts the revenue flow and leads to additional administrative costs. Practices that lack a well-defined medical billing process face these issues more frequently, making professional billing support essential.
MedSole RCM takes a proactive approach to insurance claim submission. Our team follows a rigorous multi-step process:
This system helps us maintain a high clean claim rate, claims paid on the first submission. High clean claim rates improve practice cash flow and reduce stress on staff who would otherwise manage denials and resubmissions.
Working with MedSole RCM brings practical advantages in medical billing process for your practice:
We serve physicians, clinics, and specialty practices with commitment, accuracy, and attention to detail that translates into financial peace of mind.
Claim submission and medical claim processing is not only sending the forms, it's about creating a system that keeps your revenue flowing and reduce reimbursement delays. With changing in regulations, policies of insurances, and transparency that are required by patients, your billing partner don’t need to be just efficient, but they need to be more reliable, informed, and responsive.
At MedSole RCM, our work doesn’t stop with submission. We track each claim, follow up, and provide denial resolution support. This will result in minimal payment delays and maximum revenue integrity for your practice. Contact our Team and see the difference.
A claim is a request sent to an insurer for reimbursement of healthcare services provided.
The common reasons are errors in patient data, mistakes in coding, and missing documents.
Rejected claims contain errors and are not processed. Denied claims are processed but unpaid.
Normally 7–30 days, depending on the payer.
A claim that is error-free and gets paid on the first submission.
Use accurate coding, verify insurance, and ensure complete documentation.
It's the deadline to submit a claim to an insurer.
We work with major EHRs and clearinghouses to integrate seamlessly.
Yes, we submit to all major government and private payers.
Yes, especially for procedures requiring prior approval.
Absolutely. We appeal and resubmit denied claims.
Yes, we offer reports on clean claim rates, denials, and more.
We follow payer guidelines and keep up with industry regulations.
Yes, we serve practices across the USA.
Yes, we serve specialties including cardiology, behavioral health, and more.
Medicare payments for Inpatient Psychiatric Facilities (IPFs) are set to rise by approximately 2.5% in fiscal year 2026, driven by the latest CMS rule. This regulatory update means better Medicare reimbursement for psychiatric healthcare providers. In this blog, we'll explain the details of the increase, what it means for IPFs, and how MedSole RCM's services can help psychiatric facilities optimise billing and extend the impact of this payment bump.
This steady 2.5% boost in Medicare reimbursement helps IPFs cover operational costs from staffing and treatments to facility upkeep. For psychiatric care providers already working with tight margins, it's a crucial uplift.
By preserving outlier payments at 2%, CMS ensures IPFs treating patients with complex conditions often requiring extended stays or intensive therapies continue to receive appropriate compensation.
The rule also revises facility-level payment factors relating to rural status and teaching affiliation. These adjustments bring more accurate Medicare reimbursement to IPFs operating in underserved regions or with residency training responsibilities Becker's Hospital Review+4Centers for Medicare & Medicaid Services+4Federal Register+4.
CMS applied a 3.2% market basket increase (reflecting healthcare input cost inflation), then subtracted a 0.7% productivity offset, resulting in a net 2.5% Medicare payments bump Becker's Hospital Review.
Adjusting the fixed-loss threshold keeps extra payments for high-cost cases at 2% of total costs, preventing overall reimbursement from inflating disproportionately, according to the Federal Register and the American Hospital Association.
CMS updated regression models and adjustment calculations using claims and cost data from 2019–2021. These updates better calibrate Medicare reimbursement for patient and facility characteristics like rural location and teaching status, Centres for Medicare & Medicaid Services.
As a leading medical billing company, MedSole RCM provides specialised services tailored for psychiatric providers, including Inpatient Psychiatric Facilities (IPFs):
The Medicare payments increase of 2.5% for Inpatient Psychiatric Facilities (IPFs) under CMS's FY 2026 rule offers a modest but meaningful funding boost estimated at $70 million across the sector. While it won't eliminate financial pressures, it strengthens reimbursement for operational and patient care costs. Facilities, especially those in rural areas, teaching institutions, or serving high-acuity populations, benefit from adjusted payment factors and outlier protections built into the rule.
Contact our Experts at MedSole RCM; our services help psychiatric facilities extract maximum value from this payment update. From billing and claim optimisation to quality reporting and revenue forecasting, our specialised support ensures you receive and retain every dollar Medicare intends to reimburse under the new CMS rule. Reach out to learn how we can elevate your revenue cycle and compliance efforts.
Approximately $70 million total across IPFs, about a 2.4% gain over FY 2025.
A dedicated psychiatric hospital or psychiatric unit in a general hospital certified under the Medicare IPF PPS.
Extra payments for extraordinarily costly patient stays; the update keeps them at 2% of total Medicare reimbursement.
Billing optimisation, compliance support, outlier claim audits, quality reporting assistance, and analytics for revenue tracking.
We assist in ensuring accurate data submission and adherence to new measures like 30-day ED visits post-discharge.
Through detailed analytics integration, projecting payment increases, and adjusting billing workflows accordingly.
Our expertise in psychiatric IPF reimbursement, detailed understanding of the CMS payment methodology, and tailored support ensure you maximise Medicare payments and avoid compliance pitfalls.
