Before you compare billing companies
Outsourcing medical billing changes how claims, payments, denials, outstanding balances, payer communication, and reporting move between your practice and an outside team. Before signing an agreement, define what the company will handle, what will remain with your practice, and how both sides will communicate.
These seven questions are designed to help a medical practice evaluate the working relationship. They are not a promise that outsourcing will produce a particular operational or financial result.
1. What services are included in the scope?
The phrase medical billing can describe different combinations of work. Ask whether the proposed scope includes claim submission, payment posting, reconciliation support, payer follow-up, denial work, reporting, or other defined tasks.
Request a written description of the providers, locations, payers, systems, responsibilities, exclusions, reporting schedule, and work that would require a separate agreement. Healthcode RCM defines these items before beginning ongoing billing support.
2. How will protected health information be handled?
A billing company may need access to protected health information to perform billing or claims-processing functions. Ask how access is limited, how personnel are trained, how incidents are reported, and whether subcontractors may receive or maintain protected information.
The U.S. Department of Health and Human Services identifies billing and claims processing as examples of functions that can make a vendor a business associate when protected health information is involved. HHS also explains the requirements for Business Associate Agreements between covered entities and business associates. A practice should review the arrangement with qualified compliance or legal counsel when appropriate.
3. How are billing and coding compliance questions handled?
Ask what happens when documentation is incomplete, a code cannot be supported by the available record, or a requested action may conflict with a payer or program requirement. The workflow should identify when the practice or provider must clarify the record instead of allowing an unsupported assumption to move forward.
The HHS Office of Inspector General maintains compliance guidance for individual and small group physician practices and for third-party medical billing companies. That guidance can help practices understand why written policies, training, communication, monitoring, and corrective action matter in outsourced billing relationships.
4. What reporting will the practice receive?
Ask to see the reports that will be available and confirm how often they will be delivered or discussed. Reports may cover submitted claims, payments, adjustments, aging accounts, denials, electronic rejections, and items waiting for practice action, depending on the systems and contracted scope.
Also ask who will review exceptions and pending items. A report is more useful when the practice understands what it contains, which period it covers, and which team owns the next action.
5. How are denials, rejections, and filing limits handled?
Ask how the billing company distinguishes an electronic rejection from a payer denial, documents the reason, identifies the next permitted action, and tracks follow-up. A corrected claim, appeal, documentation response, or practice action may be appropriate in different circumstances.
Filing and appeal requirements depend on the payer, program, contract, claim, and applicable rules. Ask how current requirements are checked and how accounts that cannot proceed are reported. Healthcode RCM does not guarantee that a payer will reverse a denial or issue payment.
6. What happens to existing or inherited A/R?
Do not assume that an ongoing billing agreement automatically includes every historical balance. Older accounts may have different documentation, previous actions, payer responses, filing exposure, or missing information.
Ask which date range and account types will be reviewed, how eligible accounts will be prioritized, how prior work will be evaluated, and how unworkable accounts will be reported. Healthcode RCM treats inherited or aging backlogs as a separately defined scope and does not promise a recovery percentage.
7. How will implementation and communication work?
The transition should identify who provides system access, payer information, reports, documents, contacts, and approvals. It should also define the communication schedule and the process for questions that require the practice or provider to act.
Ask for a practical implementation list covering access, responsibilities, handoffs, open items, escalation contacts, and the process for ending or transferring services. Clear documentation helps both parties understand the agreed workflow, but it does not guarantee claim acceptance, payment, or a specific financial result.
Use the same questions for every proposal
A useful comparison starts with the same questions and written answers for each company. The appropriate arrangement depends on the practice's specialty, systems, payer mix, internal responsibilities, account condition, and the exact services under consideration.
If you want to discuss a current billing workflow with Healthcode RCM, request a consultation without including patient information. We will explain what can be reviewed before proposing a scope.