Charge entry and coding review: The billing company receives your superbills or EHR charge data and reviews CPT codes, ICD-10 diagnosis codes, and modifiers for accuracy before any claim leaves your office. For small practices, this review step alone prevents a significant number of denials that would otherwise require rework three to four weeks later.

Eligibility verification: Before each appointment, your billing partner verifies the patient’s active coverage, co-pay, deductible status, and whether the requested service requires prior authorization under the patient’s specific plan. This step catches coverage gaps before services are rendered rather than after claims are denied.

Claims submission and tracking: Claims are submitted electronically through the payer’s preferred channel, tracked through the adjudication cycle, and flagged immediately when a response indicates a denial, request for information, or underpayment. Electronic submission through clearinghouses also provides a clean audit trail and faster payment compared to paper or fax-based submissions.

Denial management and appeals: Every denied claim is reviewed for the specific denial reason, corrected, and resubmitted or appealed within the payer’s timely filing window. This is the step that most in-house billing functions at small practices handle poorly, simply because the volume and deadline pressure of working denials requires dedicated staff time that a small practice cannot reliably provide.

Payment posting and reconciliation: When explanation of benefits documents and electronic remittance advice arrive, the billing team posts payments to the correct patient accounts, identifies underpayments against contracted rates, and flags discrepancies for follow-up. Underpayment recovery is a consistent source of additional revenue for practices that have not previously audited their EOBs systematically.

Reporting and practice analytics: Monthly reporting should give you clean-claim rate by payer, denial rate by reason code, days in accounts receivable, collection rate, and aging AR by bucket. These numbers tell you whether your billing is performing at benchmark or whether revenue is leaking from a specific payer or service type.

Florida has one of the most fragmented Medicaid managed care markets in the country. Patients covered by Florida Medicaid are enrolled in one of several MCOs including Sunshine Health, Simply Healthcare, Molina Healthcare, Humana Medicaid, and Staywell. Each MCO operates its own prior authorization portal, its own fee schedule, its own timely filing window, and its own documentation requirements. A billing team that does not have current working knowledge of each individual MCO is filing claims blind and reacting to denials that a more experienced team would have prevented.

In a small practice, the person handling billing is almost always also handling patient check-in, insurance verification, phone calls, and scheduling. Denial management requires concentrated time and payer-specific knowledge that is simply not available when the same person is also managing the front desk. The result is that denied claims sit in a queue, timely filing windows expire, and recoverable revenue gets written off because no one had time to work the appeal.

Common small practice coding errors include using unspecified ICD-10 codes when a more specific code is available, missing required modifiers on CPT codes, using non-covered CPT codes for specific payers, and submitting procedure codes that do not match the documented diagnosis. For example, submitting CPT 99214 for a level four evaluation and management visit without adequate documentation of medical decision making complexity in the note creates an automatic audit flag with most commercial payers and Florida Medicaid MCOs. These errors are preventable at the charge review stage and expensive to recover after the fact.

The percentage applies to net collections, not gross charges. Net collections means actual dollars received from payers and patients, not the amount you billed or the amount allowed by your contracts. If you submit $200,000 in claims and collect $130,000, the billing fee applies to the $130,000. This aligns the billing company’s incentive directly with your collections outcome.

Factors that push your rate higher: High-denial specialties such as mental health, pain management, and substance use treatment require significantly more denial management work per claim. Low average claim values mean more claims are processed per dollar collected, which increases the billing company’s workload per revenue dollar. Old accounts receivable that you bring over from a previous system or biller also typically carry a higher rate because recovery work on aged claims is more labor intensive.

Watch for minimums that change the effective rate. A quoted 4 percent rate with a $2,500 monthly minimum is not 4 percent for a practice collecting $40,000 per month. At that volume, the effective rate is 6.25 percent. Always ask the prospective vendor for their minimum monthly fee and confirm whether credentialing, old AR recovery, patient statement services, and clearinghouse fees are included or billed separately.