Medical billing in healthcare is a crucial area where the claims turn into revenue payments. Though there are many challenges involved, healthcare professionals try to manage their medical billing services in order to develop their business and patient experience. But it isn’t that easy to handle both at the same time. When they concentrate on patient responsibility, medical billing services fall at stake. It also involves mundane procedures which are to be followed if a claim goes missing or documentation is inaccurate.

Healthcare practices actually consider their contracts with insurance companies as a binding commitment, but are they really doing it? It’s unfortunate to reveal that insurance companies are ready to pay only 10-14% less than their contracted rates to practices. In case the healthcare professionals fail to pay attention to insurance payments, it means their practice is getting gouged. Eliminating underpayments is critical, but also requires education, data, and a proactive approach.

This article provides few advanced tips for medical billing in healthcare to especially deal with underpayments. Let’s check them out!

Tips for medical billing in healthcare to deal underpayments:

  1. Know what you owe
  2. Compile the entire data
  3. Approach insurance companies
  4. Stay aware
  5. Get the credentialing and licensure in order
  6. Use CAQH to simplify payer enrolment
  7. Implement timely coding for E/M services


1. Know what you owe:

  • Dividing and reviewing the insurance payer’s contracts are often tedious and time consuming. It’s also very essential and important to know what insurance companies are supposed to pay before healthcare professionals go out and get it.
  • It’s better to gather the agreements and list out each payer’s contracted rates by CPT code in a spreadsheet.
  • Healthcare professionals must use this opportunity to compare insurance companies’ rates against each other. Not only is the information useful for the next step of determining low payments, but also a crucial intel that will come in handy when they renegotiate fee schedule down the road.

2. Compile the entire data for medical billing in healthcare:

  • Along with the entire contract information, compile the whole statement as well as reimbursement data from each payer for a given amount of time for one to three months into another spreadsheet. Then compare actual payment data to the rates in the first spreadsheet at the end of the period.
  • By using advanced medical billing guidelines and software working with medical billing in healthcare, the process will be less time consuming.
  • Are insurance payers coming short? Does it happen rarely or there’s a strong tendency to underpay? What could be the average percentage of each underpayment, code by code?
  • Collect all the above information clearly and summarize it to a hand written report by explaining the scope of the issue.

3. Approach insurance companies:

  • The most crucial step is to speak up and stay heard. Follow a strategy and make a game plan beforehand. Only having your chief biller contact a low-level rep at the insurance company likely won’t result in any productive action.
  • Review the contacts carefully. Then have the practice manager request a meeting with the person at the payer, responsible for negotiating the original contract.
  • Go to the table along with data and pre-determined request whether the practitioner accepts the back payments or simply wants accurate payments in the future?
  • In case the insurance company becomes non-responsive or fails to reach an acceptable resolution to the problem, consider taking legal action.

4. Stay aware:

  • For medical billing in healthcare, the practice manager walks away from the meeting with the insurance company with a positive outcome and a commitment from them for higher, more accurate reimbursements.
  • When such a thing happens, do not let the resolution be a temporary fix. The insurance companies could easily pay the contracted rates for a few months then fall back into underpayment territory. So, pay attention!
  • Frequently audit payments from insurance companies to ensure that they are paying as promised. Regularly monitor key performance indicators to spot unhealthy payment trends.
  • If at all the issue persists, work with the medical billing in healthcare as they often have stronger and more enforced relationships with insurance companies to get back the revenue payments.

5. Get the credentialing and licensure in order:

  • Most of the insurance billing is predicted on the quality of credentialing of healthcare professionals. At the same time, the process has become increasingly difficult due to payer and state-specific requirements.
  • To manage the new practice for a solo practitioner, or add a provider to an existing facility for multi-provider practitioners, they need to start the credentialing process early.
  • It’s essential to begin credentialing 150 days prior to the date the provider plans to start seeing patients.

6. Use CAQH to simplify payer enrollment:

  • Working with insurance companies isn’t so easy, but CAQH made it possible with an initiative. It made provider enrollment with insurance companies quite simpler than it used to be earlier.
  • CAQH is a non-profit alliance that has several different initiatives focused on streamlining the business of healthcare. CAQH mostly strives to be a catalyst for industry collaboration on initiatives that simplify healthcare administration for health plans and providers in pursuit of higher quality care for patients.
  • One of the CAQH programs is Pro-View, an all-in-one platform where providers can submit, store, update, and access the information they need to work with payers.
  • Credentialing, claims processing, and quality assurance are all included in Pro-View, with credentialing being the primary service. Payers working with CAQH can use Pro-View to electronically download participating providers’ information into their systems.

7. Implement timely coding for E/M services:

  • At times, when the visit takes longer, like an extra five to ten minutes, throw off to the morning schedule.
  • The 2021 updates to Evaluation & Management coding (E&M coding) allows practices to account for this situation by billing based on the total time spent on an encounter with a patient, including both face-to-face and non-face-to-face time.
  • In medical billing in healthcare, the time spent on the following activities can be billed as E&M services provided they are accompanied by the appropriate documentation:
  1. Reviewing tests in preparation of a patient visit.
  2. Obtaining and/or reviewing separately obtained history.
  3. Performing a medically necessary appropriate examination or evaluation.
  4. Counseling and educating the patient, family, or caregiver.
  5. Ordering medications, tests, or procedures.


Medical billing in healthcare remains difficult for healthcare professionals till today. Outsourcing medical billing services would help them achieve their targets sooner than expected.


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