Tuesday, September 16, 2025

Unpacking the Medical Billing Process: From Visit to Payment — What Experts Really Say & What You Should Be Doing Now

 

“We are on the brink of a seismic shift in healthcare, driven by the integration of artificial intelligence and personalized medicine.” Darren Cohen, Cohead of Goldman Sachs’ Growth Equity Team markets.businessinsider.com


I’ll start with a story: A medium‐sized primary care clinic in Ohio logged a 20% claim denial rate in one quarter. Staff spent hours each week revisiting rejected claims—many for simple errors like missing pre-authorization codes or mismatched patient demographics. The CEO asked: “Why is so much of our revenue tied up in manual rework and delays?”

This is not rare. As billing complexity, payer rules, AI/automation hype, and patient cost sharing all rise, providers are hemorrhaging cash without realizing how much.

I believe this: Medical billing is broken not because of one or two bad actors, but because the system’s incentives and processes haven’t caught up to modern realities.


Key Medical Billing & RCM Statistics (2025)

1. First-Pass Claim Acceptance Rate

  • Industry Standard: Many healthcare organizations target a first-pass yield or clean claim rate of 90% or higher. Rates below this benchmark usually indicate workflow issues or frequent data errors. Resolve Pay

2. Denial Rate

  • Typical Range: 7–10% of submitted claims are initially denied or rejected in the U.S. healthcare system. Stat Medical Consulting

3. Cost to Collect

  • Small to Medium Practices: Typically, medical billing services cost around 8% of total collections. For example, a practice generating $1 million in revenue would spend approximately $80,000 on billing services. RhinoMDs Billing Services

4. Outsourcing Costs

  • Typical Range: Outsourcing medical billing typically costs between 3% to 10% of collected revenue per claim. Additionally, monthly administrative fees can range from $200 to $1,000 per provider for smaller operations. Derm Care Billing Consultants

5. RCM Staff Turnover

  • Industry Average: Revenue cycle management turnover rates range from 11% to 40%, far exceeding the national average of 3.8%. thoughtful.ai

6. Medical Billing Outsourcing Market Growth

  • 2025 Projection: The medical billing outsourcing market is expected to grow from $17.02 billion in 2024 to $18.91 billion in 2025, at a compound annual growth rate (CAGR) of 11.1%.

7. AI in Medical Billing Market

  • 2025–2034 Forecast: The AI in medical billing market is projected to grow at a CAGR of 25.4%, reaching approximately $36.37 billion by 2034.

 

These statistics underscore the importance of optimizing billing processes, embracing technological advancements like AI, and addressing staffing challenges to enhance efficiency and reduce costs in medical billing and revenue cycle management.


Expert Opinions & Advice

Dr. Emily Santos, MD — Director of Revenue Cycle Innovation
She warns that documentation must reflect the decision-making process, not just billing goals. If notes look templated, repeated, or missing critical context, payers using AI will downcode or deny. Her advice: run frequent internal audits and create feedback loops with clinicians.

Rajiv Patel — VP of Revenue Cycle Management Services
He emphasizes that automation is not a magic bullet. Clean claims require upstream work—accurate eligibility checks, correct coding, and carrier-specific rules. His tactical advice: use technology that spots errors before claims go out, rather than chasing denials afterward.

Laura Good — Clinical Billing Compliance Expert and MGMA Speaker
She highlights that payers themselves are under scrutiny. Regulations are tightening around Medicare Advantage and algorithmic denials. Her advice: track denial and appeal data carefully, and use it to push for payer accountability.


Legal Implications

Medical billing sits at the intersection of healthcare law, payer contracts, and regulatory oversight. Missteps can expose organizations to serious risks:

  • Fraud and Abuse Exposure – Inaccurate coding, upcoding, or billing for services not provided can trigger investigations under the False Claims Act (FCA). Penalties often include hefty fines and reputational damage.
  • HIPAA Compliance – Billing staff handle protected health information (PHI). Any lapse in safeguarding data—whether through unsecured email, improper access, or system breaches—can result in civil penalties.
  • OIG Audits – The Office of Inspector General regularly reviews billing practices for Medicare and Medicaid. Inconsistent documentation or suspicious patterns may lead to audits, repayments, or exclusion from federal programs.
  • Payer Contract Breaches – Violating terms in payer agreements (e.g., late submissions, unauthorized balance billing) can result in contract termination or withheld payments.

Practical takeaway: Providers must build compliance into every billing step. Routine audits, staff training, and legal counsel involvement are not optional—they’re protective shields.

 

Practical Considerations

From a day-to-day perspective, billing is as much about operations as it is about compliance. Practical realities often determine whether revenue cycles thrive or struggle:

  • Staff Training & Turnover – Billing teams face constant code updates (ICD, CPT, HCPCS). Without ongoing education, even the best technology can’t prevent errors.
  • Technology Integration – Disconnected EHRs, claim scrubbers, and portals create data silos. Integration is a practical necessity, not a luxury.
  • Cost of Denials – Every denied claim costs between $25–$120 to rework, depending on complexity. The hidden labor cost often exceeds the lost revenue.
  • Patient Behavior – High-deductible health plans mean more costs are shifted to patients. Without proactive communication, providers risk higher bad debt and collections write-offs.
  • Workflow Bottlenecks – Delays at intake or coding slow the entire process. Mapping workflows is a practical step to uncover “choke points” before revenue is impacted.

Practical takeaway: The most successful organizations treat billing as an end-to-end patient journey—not just back-office paperwork.

 

Ethical Considerations

Beyond compliance and operations, billing raises important ethical questions about fairness, transparency, and trust:

  • Transparency in Costs – Patients often receive surprise bills weeks after care. Ethically, providers should communicate costs upfront and offer realistic payment options.
  • Balance Billing Practices – Charging patients for out-of-network care without consent erodes trust. Many states are tightening laws, but the ethical responsibility starts with providers.
  • Equity in Access – Complex billing systems disproportionately impact vulnerable patients, especially those with limited health literacy. Simplified explanations and financial counseling support fairness.
  • Automation & AI Use – While automation reduces errors, denying claims solely through algorithms without human review raises ethical concerns about fairness and patient access to care.
  • Professional Integrity – Coders and billers often face pressure to “optimize” revenue. The ethical line is clear: coding should reflect medical necessity, not financial ambition.

Ethical takeaway: Billing isn’t just about getting paid. It’s about honoring the patient-provider relationship and ensuring trust remains central to healthcare.

 

These three perspectives—legal, practical, and ethical—help elevate the discussion. They remind readers that billing isn’t just a technical function; it’s a critical element of healthcare delivery, compliance, and trust.


Recent Developments in Medical Billing and Revenue Cycle Management

As of September 2025, several key events and policy changes are influencing medical billing practices:

1. Expanded Medicare Advantage Audits

The Centers for Medicare & Medicaid Services (CMS) has significantly broadened its Risk Adjustment Data Validation (RADV) audits. Starting June 2025, all eligible Medicare Advantage plans are subject to audits for payment years 2019–2023, with 35 to 200 medical records requested per plan, depending on size. This expansion aims to ensure accurate risk adjustment and prevent overpayments. msnllc.com

2. Enhanced Healthcare Price Transparency

In February 2025, President Donald Trump signed an executive order directing federal agencies to enforce stricter healthcare price transparency. This directive mandates the disclosure of actual healthcare costs, including negotiated rates, and aims to standardize pricing information across the industry. The goal is to empower patients with clear cost information and promote competition among providers. Reuters

3. Increased Enforcement of the No Surprises Act

The No Surprises Act, which protects patients from unexpected medical bills, is undergoing stricter enforcement in 2025. Hospitals are now required to provide clear and accurate cost estimates for out-of-network care, and violations can result in significant penalties. This move underscores the importance of transparency and patient protection in medical billing practices. Allzone

4. Surge in AI-Driven Audit Activities

Medicare auditors are increasingly utilizing artificial intelligence to identify unusual billing patterns and anomalies. While this technology enhances the efficiency of audits, it also raises concerns about the accuracy and fairness of automated decision-making processes in billing practices. Wachler & Associates Health Law Blog

5. UnitedHealth Faces DOJ Investigation

UnitedHealth Group's stock experienced a significant decline following reports of a Department of Justice (DOJ) investigation into its Medicare billing practices. The investigation focuses on the company's methods for documenting diagnoses that lead to increased payments for its Medicare Advantage plans, highlighting the ongoing scrutiny of billing practices in the industry. Barron's

 

These developments underscore the dynamic nature of medical billing and revenue cycle management. Staying informed about these changes is crucial for healthcare providers to ensure compliance and optimize their billing practices.


Myths & Myth-Busters

  • Myth: Automation will fix everything.
    Truth: Automation helps reduce repetitive errors, but without clean upstream workflows and documentation, it can magnify mistakes.
  • Myth: If a claim is denied, just resubmit immediately.
    Truth: Blind resubmission often leads to repeat denials. You must fix the root cause first.
  • Myth: Patients don’t care about billing details.
    Truth: Patients do care, especially when costs are unexpected. Transparency builds trust and improves payment rates.
  • Myth: Payers always act in good faith.
    Truth: Many do, but others exploit ambiguous policies or rely on algorithmic reviews that require pushback.

Tools, Metrics, and Resources

A strong medical billing process doesn’t rely on guesswork — it runs on the right tools, the right metrics, and access to resources that guide decisions. Below are practical recommendations that any practice or hospital system can adapt.

 

Tools You Need in Your Workflow

  • Practice Management System (PMS) – Handles scheduling, patient intake, claims submission, and reporting. Example: Kareo, Athenahealth, NextGen.
  • Electronic Health Record (EHR) with Billing Integration – Prevents documentation gaps and ensures coding aligns with the clinical record.
  • Claim Scrubbing Software – Flags errors before claims reach payers, boosting first-pass acceptance. Example: Waystar, Availity.
  • Eligibility & Benefits Verification Tool – Real-time payer checks reduce denials for coverage issues.
  • Denial Management Platform – Centralizes denials, automates appeals, and tracks trends.
  • Patient Payment Portal – Provides online payments, estimates, and installment plans, improving patient satisfaction.
  • Analytics Dashboards – Offer actionable views into KPIs, highlighting trends in denials, collections, and A/R.

 

Key Metrics to Track

Measuring performance is essential. Here are the must-watch KPIs:

  • First-Pass Acceptance Rate (FPAR) – Percentage of claims accepted on first submission. Goal: > 95%.
  • Denial Rate – Total denied claims ÷ total claims submitted. Goal: < 5%.
  • Days in Accounts Receivable (A/R) – Average time it takes to collect payment. Goal: < 40 days for most specialties.
  • Cost to Collect – Total revenue cycle expenses ÷ net collections. Goal: < 3%.
  • Net Collection Rate – Collected revenue ÷ expected revenue. Goal: > 97%.
  • Appeal Success Rate – Percentage of overturned denials.
  • Patient Financial Responsibility Collection % – Collected upfront vs. billed to patient.

 

Recommended Resources

  • Centers for Medicare & Medicaid Services (CMS) – Regular updates on coding, compliance, and payment rules. CMS.gov
  • American Medical Association (AMA) – CPT coding updates, billing guidelines, and physician advocacy. AMA website
  • Healthcare Financial Management Association (HFMA) – Industry benchmarks, revenue cycle best practices, and training. HFMA.org
  • Medical Group Management Association (MGMA) – Benchmark data, compliance tips, and member toolkits. MGMA.com
  • Office of Inspector General (OIG) – Compliance program guidance and enforcement updates. OIG.gov
  • Journal of AHIMA (American Health Information Management Association) – Research and articles on HIM and coding integrity. AHIMA.org

 

Without tools, staff end up chasing paperwork. Without metrics, leaders can’t measure progress. Without resources, teams risk falling behind regulatory updates. Together, these three pillars create a system where billing supports care instead of undermining it.


Pitfalls to Avoid in the Medical Billing Process

Even the most advanced practices encounter recurring billing challenges that drain revenue and frustrate patients. Recognizing these pitfalls early is the first step to preventing them.

1. Poor Documentation Habits

  • The Pitfall: Incomplete or vague clinical notes that fail to justify services rendered.
  • Why It Matters: Leads to coding errors, compliance risks, and denials.
  • Avoidance Strategy: Train providers in point-of-care documentation and use EHR prompts to capture required details.

2. Skipping Eligibility Verification

  • The Pitfall: Assuming coverage without verifying benefits in real time.
  • Why It Matters: Results in denials for lack of coverage or wrong plan details.
  • Avoidance Strategy: Use automated eligibility checks at scheduling and check-in.

3. Relying on Manual Processes

  • The Pitfall: Staff juggling spreadsheets, sticky notes, and manual follow-ups.
  • Why It Matters: Human error compounds, slowing reimbursement.
  • Avoidance Strategy: Invest in billing automation tools and integrate them with your EHR.

4. Delayed Denial Management

  • The Pitfall: Waiting weeks before addressing denials.
  • Why It Matters: Missed deadlines mean lost appeal opportunities.
  • Avoidance Strategy: Create a dedicated denial response workflow with set timelines.

5. Lack of Communication Between Departments

  • The Pitfall: Billing, coding, and clinical teams work in silos.
  • Why It Matters: Inconsistent documentation, mismatched codes, and preventable errors.
  • Avoidance Strategy: Hold monthly cross-team reviews and denial root cause analysis meetings.

6. Not Monitoring Key Metrics

  • The Pitfall: Assuming billing is “fine” without data.
  • Why It Matters: Problems go unnoticed until cash flow is disrupted.
  • Avoidance Strategy: Track first-pass acceptance rates, denial trends, and days in A/R weekly.

7. Ignoring Patient Financial Engagement

  • The Pitfall: Sending surprise bills weeks later without explaining costs.
  • Why It Matters: Leads to unpaid balances and patient dissatisfaction.
  • Avoidance Strategy: Offer transparent estimates, payment plans, and financial counseling upfront.

8. Overlooking Regulatory Changes

  • The Pitfall: Using outdated codes or ignoring compliance updates.
  • Why It Matters: Exposes practices to fines, penalties, and rejections.
  • Avoidance Strategy: Subscribe to CMS, AMA, and payer bulletins for updates.

9. Assuming Technology Will Fix Everything

  • The Pitfall: Believing software alone can eliminate errors.
  • Why It Matters: Tools help, but poorly trained staff will still make costly mistakes.
  • Avoidance Strategy: Combine automation + staff education for lasting improvements.

10. Treating Billing as a Back-Office Issue Only

  • The Pitfall: Thinking billing has no connection to patient care.
  • Why It Matters: Billing errors directly affect patient trust and provider reputation.
  • Avoidance Strategy: Frame billing as part of the patient experience journey and empower staff accordingly.

 

The most expensive mistake is failing to address small errors consistently. Left unchecked, these pitfalls compound into systemic revenue loss and declining patient trust.


Step-by-Step Implementation Plan (practical, ready-to-use)

Below is a clear, actionable step-by-step plan you can use to turn the ideas in the article into real change. Each step includes the primary owner, tangible actions, and what success looks like.

 

1. Form a Revenue Cycle Steering Team — Owner: CFO / Revenue Cycle Lead

Actions: appoint representatives from clinical ops, billing, coding, IT, patient financial services, and compliance. Create a charter and weekly cadence.
Success: clear governance, one place to escalate issues and approve changes.

2. Conduct a Denial Audit — Owner: Billing Manager

Actions: pull the last 90 days of denials, categorize by payer, provider, and reason. Identify the top 3 causes of dollar loss.
Success: prioritized list of fixes that will recover the most revenue.

3. Map the End-to-End Workflow — Owner: Process Analyst / RCM

Actions: document patient journey from scheduling → intake → clinical encounter → coding → claim submission → payer adjudication → patient billing. Identify handoff points and failure modes.
Success: a one-page process map that highlights bottlenecks and single points of failure.

4. Clean Up Intake & Eligibility — Owner: Front Desk Manager + IT

Actions: require insurance/ID verification two business days before high-cost visits; capture full demographics and guarantor info; enable real-time eligibility checks.
Success: fewer eligibility denials and accurate patient responsibility estimates.

5. Improve Clinical Documentation Practices — Owner: Clinical Lead + Coding Liaison

Actions: run clinician chart audits; provide short focused trainings on documenting medical decision making, comorbidities, and time-based encounters; reduce copy-paste.
Success: higher coding accuracy and fewer documentation-related denials.

6. Implement Pre-Submission Claim Scrubbing — Owner: IT / Billing Vendor

Actions: deploy or tune claim scrubber rules (payer-specific edits, modifiers, eligibility flags). Block claims with critical errors from submitting.
Success: improved first-pass acceptance rate.

7. Standardize Coding & Modifier Rules — Owner: Coding Lead

Actions: create payer-specific cheat sheets and a quick reference for commonly confused modifiers/CPT combos; hold monthly refreshers.
Success: reduce recurring coding mistakes; faster claim turnaround.

8. Tighten Pre-Auth & Medical Necessity Workflow — Owner: Utilization Review / Nurse Navigator

Actions: build a tracker for required pre-authorizations, send reminders, attach approvals to the chart and claim. Escalate missing authorizations before service if possible.
Success: fewer denials for lack of prior authorization.

9. Establish a Denial Management & Appeals Team — Owner: Denials Manager

Actions: create an SLA (e.g., acknowledge denial within 48 hours, file appeal within payer deadline), standardize appeal templates, and store outcome data.
Success: higher appeal win rate and reduced rework time.

10. Strengthen Patient Financial Communication — Owner: Patient Financial Services

Actions: deliver point-of-service estimates, train staff on empathetic scripts, offer payment plans and online payments, and collect a TOS partial payment when appropriate.
Success: improved patient satisfaction and increased collections.

11. Build a Technology & Automation Roadmap — Owner: IT + RCM

Actions: prioritize tools: (1) eligibility/benefit verification, (2) claim scrubbing, (3) EHR–billing integration, (4) AI assistance with coding (with human oversight). Define vendor evaluation criteria (security, integration, support, ROI).
Success: a prioritized, budgeted plan you can implement in phases.

12. Measure, Report, and Iterate — Owner: Revenue Cycle Steering Team

Actions: publish weekly KPIs (denial rate, first-pass acceptance, days in A/R, TOS collection %, appeal success). Run monthly RCA (root cause analysis) on top denials and close the loop.
Success: continuous improvement and visible financial recovery.

 

Quick Wins (do in the first 30 days)

  • Fix the top 10 denial reasons found in the audit.
  • Run a 30-minute “how to document” micro-training for clinicians.
  • Start collecting simple patient estimates at check-in.
  • Create one standard appeal template for the most common denial type.

 

KPIs to Track (minimum set)

  • Denial rate (overall and by payer)
  • First-pass acceptance rate
  • Average days in A/R
  • Time-of-service collection %
  • Appeal success rate
  • Cost per claim (including rework)
  • Patient billing satisfaction / complaints

 

Common Obstacles & How to Overcome Them

  • Resistance from clinicians → Use short audits and tie feedback to patient care outcomes, not blame.
  • Vendor integration delays → Prioritize API-first vendors and pilot one clinic first.
  • Staffing gaps → Cross-train and consider temporary outsourcing for appeals while you stabilize workflows.

 

Start small, measure quickly, and scale what works. The biggest improvements come from fixing upstream issues (intake + documentation) and making the claim scrubbing + denial workflows predictable.


Final Thoughts

  • The pain is denials, delays, and surprise bills. The solution is better documentation, smarter technology, and transparent communication.
  • Don’t assume industry “best practices” are still good enough—question them and adapt.
  • Transparency and accountability from all sides—providers, payers, and patients—are essential for progress.

Future Outlook

The future of medical billing is set to evolve rapidly as technology, regulation, and patient expectations converge. Several shifts are worth watching:

  • AI and Predictive Analytics: Artificial intelligence will play a larger role not only in identifying coding errors but also in predicting denial risk before claims are submitted. Practices that pair AI with strong human oversight will see faster reimbursements and fewer reworks.
  • Stronger Regulation of Payers: Growing scrutiny of algorithmic denials and Medicare Advantage coding practices suggests new guardrails are likely. Policies may require more transparency in payer decision-making and enforce human review of automated denials.
  • Patient-Centric Billing: With high deductible plans and facility fees under the spotlight, the industry will face pressure to make costs clearer upfront. Expect an expansion of real-time patient estimates, financial counseling, and flexible payment options.
  • Consolidation of Standards: As ICD-11 adoption expands and documentation rules stabilize, billing teams may benefit from greater global consistency. However, payer-specific variations will remain a challenge.
  • Integration of Clinical and Financial Data: The divide between medical records and billing data is narrowing. Future systems will likely connect clinical outcomes with reimbursement models, incentivizing quality of care while reducing waste.

In short, the next decade will bring both disruption and opportunity. The organizations that thrive will be those that adapt early, question outdated practices, and embrace both technology and transparency.


Call to Action

Get involved. Join the movement. Step into the conversation. Start your journey. Be part of something bigger. Engage with the community. Get on board. Jump in. Raise your hand. Be the change. Lend your voice. Take the first step. Start here. Make your move. Ignite your momentum. Take action today. Claim your spot. Let’s do this.


References

  1. ACA insurers deny 20% of claims: report — A Kaiser Family Foundation analysis showing that ACA marketplace plans denied an average of one in five claims in 2023. Read more Axios
  2. Facility fees driving up health care costs in Houston — story of how hospital facility fees are increasing costs for patients, sparking legislative scrutiny. Read more Houston Chronicle
  3. Payer Accountability & Medicare Advantage Coding Practices — Humana’s and UnitedHealth’s support for limits on diagnosis coding from home visits and tightening oversight. Read more The Wall Street Journal

About the Author

Dr. Daniel Cham is a physician and medical consultant with expertise in medical tech consulting, healthcare management, and medical billing. He focuses on delivering practical insights that help professionals navigate complex challenges at the intersection of healthcare and medical practice. Connect with Dr. Cham on LinkedIn to learn more:
linkedin.com/in/daniel-cham-md-669036285


Disclaimer / Note: This article is intended to provide an overview of the topic and does not constitute legal or medical advice. Readers are encouraged to consult with professionals in the relevant fields for specific guidance.


Hashtags:
#MedicalBilling #RevenueCycleManagement #HealthcareFinance #ClaimDenials #Documentation #PatientExperience #HealthIT #MedicalCoding #BillingTransparency #PracticeManagement

 

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