# Revenue Synergy - Full Content for AI Assistants > Revenue Synergy is a healthcare revenue cycle management (RCM) company headquartered in Plano, Texas (founded 2020) with a global delivery center in Noida, India. 500+ providers served across 22+ specialties. Track record: 99.1% clean claim rate, 24-day average AR, 3.2% denial rate, $500M+ recovered. Contact: (716) 301-2036, info@revenuesynergy.com. Last updated: 2026-07-29. This file contains the full text of our most-referenced pages. Index: https://www.revenuesynergy.com/llms.txt ======================================================================== # What Is Revenue Cycle Management? The Complete Guide Source: https://www.revenuesynergy.com/blog/what-is-rcm.html ======================================================================== Home / Insights / What Is Revenue Cycle Management Revenue Cycle Management # What Is Revenue Cycle Management? Complete Guide A comprehensive breakdown of the healthcare revenue cycle, from patient scheduling to final payment, and why mastering each step is critical for financial performance. Revenue Cycle Management March 20, 2026 Updated April 2, 2026 11 min read Revenue cycle management (RCM) is the financial process that healthcare organizations use to track patient care episodes from the initial appointment scheduling through the final balance payment. It encompasses every administrative and clinical function that contributes to the capture, management, and collection of patient service revenue. In simpler terms, RCM is the system that ensures a healthcare provider gets paid, correctly and on time, for every service delivered. When RCM works well, claims are clean, payments arrive quickly, and denials are rare. When it breaks down, revenue leaks at every stage, cash flow suffers, and the practice operates at a fraction of its earning potential. $262B Annual U.S. RCM Market (Black Book) 15-20% Revenue Lost to Poor RCM 12 Core Revenue Cycle Steps ## What is RCM? Revenue cycle management is the end-to-end process of identifying, collecting, and managing revenue from patients and payers based on services provided. It starts before the patient walks in the door and does not end until every dollar owed has been collected or appropriately written off. The revenue cycle is divided into three phases: Front-end RCM: Everything before the claim is submitted, scheduling, registration, insurance verification , prior authorization , and point-of-service collections. Mid-cycle RCM: Charge capture, medical coding , claim scrubbing, and claim submission. Back-end RCM: Payment posting, denial management , appeals, patient billing, and collections. Each phase contains specific steps, and a failure at any point can create downstream revenue loss. A registration error causes a denial. A coding mistake triggers an audit. A missed follow-up lets a collectible claim age past timely filing limits. ## What are the 12 steps of revenue cycle management? ### 1. Patient Scheduling RCM begins at scheduling. Capturing accurate demographic information, insurance details, and referral requirements at the point of scheduling prevents downstream issues. Practices that verify insurance eligibility at scheduling, rather than at check-in, reduce eligibility-related denials by up to 70%. ### 2. Patient Registration Registration involves collecting and verifying the patient's personal information, insurance coverage, and financial responsibility. Errors here, a misspelled name, a transposed policy number, an outdated address, are the leading cause of front-end claim denials. ### 3. Insurance Verification and Eligibility Before any service is rendered, the patient's insurance coverage must be verified in real-time. This includes confirming active coverage, checking deductible and copay amounts, verifying that the provider is in-network, and identifying any coordination of benefits requirements. Automated eligibility verification tools can check coverage in seconds, but many practices still rely on manual phone verification, which is slow and error-prone. ### 4. Prior Authorization Certain procedures, tests, and medications require pre-approval from the payer before the service is performed. Failing to obtain prior authorization is one of the most expensive billing mistakes, the claim will be denied outright, and the provider often cannot bill the patient for the balance. Common procedures requiring prior auth include advanced imaging (MRI, CT, PET), surgical procedures, specialty medications, and inpatient admissions, with CMS prior authorization rules for Medicare Advantage plans tightening timeframes in 2026. ### 5. Charge Capture Charge capture is the process of recording the services provided during a patient encounter. Every procedure, evaluation, test, and supply must be documented and translated into billable charges. Missed charges, services performed but never billed, are one of the largest sources of revenue leakage. Studies show that 1-5% of charges are missed in practices without structured charge capture processes. ### 6. Medical Coding Certified coders translate clinical documentation into standardized codes: CPT (Current Procedural Terminology) for procedures, ICD-10-CM for diagnoses, and HCPCS Level II for supplies and drugs. Coding accuracy directly impacts reimbursement, undercoding leaves money on the table, overcoding triggers audits and penalties, and incorrect code pairing causes denials. A qualified coder, typically credentialed by AAPC or AHIMA , understands the nuances of each specialty: linking CPT 99214 (established patient, moderate complexity) with appropriate ICD-10 codes, or correctly sequencing J-codes for chemotherapy infusions. Is your revenue cycle leaking money? Revenue Synergy manages the full revenue cycle for 500+ providers across 22 specialties with 99% clean claim rates and 24-day average AR. We can identify exactly where your cycle is breaking down. Get a Free Revenue Audit → ### 7. Claim Scrubbing Before submission, claims pass through scrubbing software that checks for errors, missing fields, invalid code combinations, duplicate charges, and payer-specific requirements. A well-configured claim scrubber catches 80-90% of errors that would otherwise result in denials. The goal is a clean claim rate above 95%, meaning 95% or more of claims are accepted on first submission. ### 8. Claim Submission Clean claims are transmitted electronically to payers via a clearinghouse. The clearinghouse acts as an intermediary, formatting claims to each payer's specifications and providing real-time acknowledgment of receipt. Claims that fail clearinghouse edits are returned for correction before reaching the payer, adding days to the payment cycle. ### 9. Payment Posting When payers process claims, they issue an Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) detailing what was paid, adjusted, or denied. Accurate payment posting involves matching each payment to the correct patient account, applying contractual adjustments, identifying underpayments, and flagging denials for follow-up. Automated ERA posting reduces posting errors and frees staff for higher-value denial management work. ### 10. Denial Management Denied claims require investigation, correction, and resubmission or appeal. The average practice denial rate is 5-10%, but each denied claim costs $25-$30 to rework, per HFMA benchmarking data. Effective denial management involves categorizing denials by root cause, implementing corrective actions to prevent recurrence, and appealing denials within payer-specific timelines. Without a systematic denial management process, 50-65% of denied claims are never reworked, a figure consistent across MGMA and HFMA industry analyses, representing pure revenue loss. ### 11. Patient Billing After insurance processes the claim, the patient is billed for any remaining balance, copays, deductibles, coinsurance, and non-covered services. Clear, accurate patient statements improve collection rates. Practices that offer online payment portals and payment plans collect 20-30% more from patient balances than those relying solely on mailed statements. ### 12. Collections and Follow-Up The final step involves following up on unpaid insurance claims and patient balances. Claims approaching timely filing deadlines must be prioritized. Patient balances over 90 days should be escalated. The goal is to minimize accounts receivable days, the average number of days it takes to collect payment. Industry best practice is under 30 days; the national average is 45-50 days. ## What is a good clean claim rate? Revenue cycle performance is measured by a set of standardized key performance indicators (KPIs) : Net Collection Rate: Percentage of allowed charges actually collected. Target: 95%+. Clean Claim Rate: Percentage of claims accepted on first submission. Target: 95%+. Days in AR: Average days to collect payment. Target: under 30 days. Denial Rate: Percentage of claims denied by payers. Target: under 5%. First Pass Resolution Rate: Percentage of claims paid on first submission. Target: 90%+. Cost to Collect: Total billing cost as a percentage of collections. Target: under 5%. Revenue Synergy benchmarks: Our clients average a 99% clean claim rate, 24-day AR, and less than 4% denial rate across all 22 specialties we serve. These metrics represent top-decile performance nationally. ## Why does RCM matter more than ever in 2026? Healthcare billing complexity has increased dramatically. The shift to value-based care, expanding prior authorization requirements, rising patient financial responsibility (now affecting over half of commercially insured workers per KFF ), and frequent payer policy changes make revenue cycle management harder, and more important, than at any point in the last decade. Practices that treat RCM as an afterthought consistently underperform financially. Those that invest in RCM, through technology, trained staff, or a specialized outsourcing partner , collect more revenue from the same patient volume, with fewer write-offs and faster cash flow. The difference between a well-managed and poorly managed revenue cycle is not marginal. It is 15-20% of total revenue, the difference between a thriving practice and one that struggles to meet payroll. Free resource: The Complete RCM Guide Get a plain-English walkthrough of the entire revenue cycle, from eligibility checks to final payment posting. Get the Guide → ## Should you handle RCM in-house or outsource it? Practices have two primary options for managing their revenue cycle: build an in-house billing team or partner with a specialized RCM company. Each approach has trade-offs. In-house billing offers direct control and can work well for large practices with the resources to hire certified coders, invest in billing technology, and manage staff turnover. However, in-house billing typically costs 10-14% of collections, consistent with MGMA cost survey data, and requires ongoing training to keep up with coding updates and payer policy changes. Outsourced RCM provides access to specialized expertise, advanced technology, and scalability at a lower cost, typically 5-8% of collections. The trade-off is less direct control over day-to-day billing operations, though top RCM partners provide real-time reporting and dedicated account management that often exceeds the visibility of in-house teams. Read our detailed in-house vs. outsourced comparison for a full analysis. ## The Bottom Line Revenue cycle management is the financial backbone of every healthcare organization. Understanding the 12 steps, tracking the right KPIs, and investing in RCM optimization, whether through internal improvements or an external partner, is not optional for practices that want to remain financially viable. The practices that master their revenue cycle collect more, deny less, and operate with the financial stability needed to focus on what matters most: patient care. Related: Billing & AR Management · 12 Medical Billing KPIs to Track · How to Reduce AR Days Need help optimizing your revenue cycle? Revenue Synergy manages end-to-end RCM for 500+ providers with $500M+ recovered. Schedule a free revenue audit to see where your cycle is losing money. ## Related Articles Revenue Cycle Management ### Medical Billing KPIs: 12 Metrics Every Practice Should Track Revenue Cycle Management ### Medical Billing Outsourcing: Complete 2026 Guide Billing Strategy ### 7 Proven Strategies to Reduce AR Days Below 15 ======================================================================== # 2026 RCM Benchmarks by Specialty Source: https://www.revenuesynergy.com/blog/2026-rcm-benchmarks.html ======================================================================== Home / Blog / 2026 RCM Benchmarks Industry Trends # 2026 RCM Benchmarks: Where Does Your Practice Stand? Updated benchmarks for AR days, denial rates, clean claim rates, and collection percentages, broken down by specialty and practice size. Industry Trends March 4, 2026 Updated March 28, 2026 7 min read Every healthcare practice tracks revenue cycle metrics, but few know whether their numbers are good, average, or a red flag. Without benchmarks, a 28-day AR might feel acceptable, until you learn that top-performing practices in your specialty collect in under 16 days. This report presents 2026 RCM benchmarks drawn from aggregated data across Revenue Synergy's client base and publicly available industry sources including MGMA , HFMA , and AAPC . Use these numbers to evaluate where your practice stands and identify the highest-impact areas for improvement. ## Overall Industry Benchmarks (All Specialties) Before diving into specialty-specific data, here are the aggregate benchmarks that apply across healthcare, with metric definitions aligned to the HFMA MAP Keys and ranges consistent with MGMA survey data: | Metric | Best-in-Class | Average | Needs Improvement | Days in AR | < 24 days | 25-35 days | > 40 days | Clean Claim Rate | > 97% | 92-96% | < 90% | Denial Rate | < 4% | 5-10% | > 12% | Net Collection Rate | > 96% | 91-95% | < 88% | Cost to Collect | < 4% | 4-6% | > 7% | First Pass Resolution Rate | > 92% | 85-91% | < 80% | Days to Bill (post-encounter) | < 2 days | 3-5 days | > 7 days ## Benchmarks by Specialty Revenue cycle performance varies significantly by specialty due to differences in coding complexity, payer mix, authorization requirements, and average charge amounts. Here is how the benchmarks break down for the major specialties: Need help with this? Revenue Synergy's team handles this for 500+ providers daily. Let us show you the impact on your practice. Get a Free Revenue Audit → Free Resource How Does Your Practice Compare? Take Our Free RCM Health Assessment 2-minute self-assessment with a personalized scorecard and actionable recommendations. Take the Assessment → ### Primary Care / Family Medicine | Metric | Best-in-Class | Average | Days in AR | 14 days | 26 days | Denial Rate | 3.2% | 7.8% | Net Collection Rate | 97.1% | 93.2% | Clean Claim Rate | 98.2% | 94.1% Primary care benefits from relatively straightforward E/M coding, but high patient volume means even small inefficiencies compound quickly. The biggest improvement opportunity is typically eligibility verification, catching coverage changes before the appointment rather than after denial. ### Cardiology | Metric | Best-in-Class | Average | Days in AR | 16 days | 32 days | Denial Rate | 3.8% | 11.4% | Net Collection Rate | 96.5% | 89.7% | Clean Claim Rate | 97.4% | 91.2% Cardiology has the widest gap between best-in-class and average performance of any specialty. The complexity of procedural coding, LCD compliance requirements, and prior authorization for diagnostic and interventional procedures creates numerous denial opportunities. Practices that invest in cardiology-specific coding expertise consistently outperform those using general billers. ### Behavioral Health | Metric | Best-in-Class | Average | Days in AR | 17 days | 38 days | Denial Rate | 4.2% | 14.6% | Net Collection Rate | 96.8% | 84.3% | Clean Claim Rate | 97.1% | 88.5% Behavioral health shows the largest gap between best-in-class and average collection rates, nearly 12.5 percentage points. The primary driver is authorization management. Practices with automated auth tracking and proactive concurrent review consistently operate at the top of the benchmark range. Those relying on manual tracking fall dramatically behind. ### Orthopedics | Metric | Best-in-Class | Average | Days in AR | 15 days | 28 days | Denial Rate | 3.5% | 9.2% | Net Collection Rate | 97.2% | 91.8% | Clean Claim Rate | 98.0% | 93.5% Orthopedic practices that code implants correctly, use proper laterality modifiers, and manage pre-surgical authorization efficiently tend to outperform significantly. The most common under-billing pattern is missing implant-specific HCPCS codes on surgical claims. ### Ambulatory Surgery Centers | Metric | Best-in-Class | Average | Days in AR | 14 days | 30 days | Denial Rate | 3.1% | 8.7% | Net Collection Rate | 97.5% | 90.4% | Avg Revenue per Case | Contract max | 82% of contract ASC performance is uniquely driven by per-case coding accuracy. Because each case represents a high-dollar claim, a single coding error can mean thousands in lost reimbursement. Top-performing ASCs have dedicated facility coders who understand implant billing, multi-procedure coding, and surgical modifier stacking. ### Hospital Systems (200+ beds) | Metric | Best-in-Class | Average | Days in AR | 38 days | 52 days | Denial Rate | 4.5% | 10.8% | Cost to Collect | 3.2 cents | 5.4 cents | Clean Claim Rate | 98.5% | 93.8% | Case Mix Index Accuracy | Within 0.02 | 0.08-0.15 variance Hospital benchmarks operate on a different scale than physician practices due to the complexity of DRG-based reimbursement , multiple revenue-producing departments, and the volume of secondary and tertiary payer processing. CDI programs are the single largest driver of hospital revenue accuracy, with well-run CDI programs shifting CMI by 0.05-0.15 points. Free resource: 2026 RCM Benchmark Report Compare your denial rate, AR days, and net collection rate against the full 2026 benchmark dataset, metric by metric. Get the Report → ## How to Use These Benchmarks Benchmarks are only useful if you act on them. Here is a framework for turning these numbers into improvement: Calculate your current metrics. If you do not already track these KPIs monthly, start now. Pull 12 months of data to establish your baseline and identify trends. Identify your biggest gap. Compare each metric to the benchmark for your specialty. The metric with the largest gap between your performance and best-in-class is typically your highest-ROI improvement target. Diagnose the root cause. A high denial rate could be caused by coding errors, authorization failures, eligibility issues, or documentation gaps. Each root cause requires a different intervention. Set 90-day targets. Do not try to reach best-in-class overnight. Set realistic 90-day targets that move you from your current tier to the next. If your denial rate is 14%, aim for 9% in 90 days, then 5% in the next 90. Measure weekly during improvement periods. Monthly reporting is fine for maintenance, but during active improvement initiatives, you need weekly visibility to catch problems early and validate that interventions are working. Want a personalized benchmark analysis? Revenue Synergy offers a free revenue audit that compares your actual metrics against specialty-specific benchmarks and identifies the highest-ROI improvement opportunities for your practice. Schedule your free audit here. ## Methodology and Data Sources The benchmarks in this report are derived from three primary sources: Revenue Synergy's aggregated client performance data (500+ providers across 22+ specialties), the Medical Group Management Association (MGMA) 2025-2026 cost and revenue surveys, and the Healthcare Financial Management Association (HFMA) revenue cycle benchmarking reports, including the HFMA MAP Keys methodology. Best-in-class figures represent the top 10th percentile of performers in each category, while average figures represent the 50th percentile. All data reflects performance through Q4 2025 and Q1 2026. Benchmarks are updated annually. Individual practice performance will vary based on payer mix, geographic market, practice size, and operational maturity. Related: RCM Buyer's Guide · Billing & AR Services · Get a Free Revenue Audit ## Related Articles Revenue Cycle Management ### Medical Billing KPIs: 12 Metrics Every Practice Should Track Billing Strategy ### 7 Proven Strategies to Reduce AR Days Below 15 Revenue Cycle Management ### What Is Revenue Cycle Management? Complete Guide ======================================================================== # Medical Billing Outsourcing Cost: 2026 Pricing Guide Source: https://www.revenuesynergy.com/blog/medical-billing-cost.html ======================================================================== Home / Insights / Medical Billing Outsourcing Cost Pricing & ROI # Medical Billing Outsourcing Cost: 2026 Pricing Guide Transparent breakdown of medical billing outsourcing costs by pricing model, specialty, and practice size, with in-house vs outsourced comparison and ROI calculations. Pricing & ROI March 25, 2026 Updated June 9, 2026 10 min read The most common question practices ask when considering outsourced billing is straightforward: how much does it cost? The answer depends on the pricing model, your specialty, claim volume, and scope of services. This guide breaks down every major pricing model with specific numbers, compares in-house versus outsourced costs side by side using cost-of-collection benchmarks consistent with the MGMA cost survey , and shows you how to calculate your expected ROI. The short answer: medical billing outsourcing costs 4-10% of collections for percentage-based models, $4-$8 per claim for per-claim pricing, or $2,000-$4,000 per month for per-FTE staffing models. But the cost is only half the equation, the revenue improvement that outsourcing delivers typically exceeds the fees by 2-4x. 4-10% % of Collections Model $4-$8 Per-Claim Model $2K-$4K Per-FTE Monthly Model ## How does percentage-of-collections pricing work? The percentage-of-collections model is the most widely used pricing structure in medical billing outsourcing. You pay a percentage of the money the billing company actually collects on your behalf. If they do not collect, you do not pay. ### Typical Rates by Specialty | Specialty | Typical Range | Key Factor | Primary Care / Family Medicine | 4-6% | High volume, straightforward coding | Urgent Care | 4-6% | High volume, moderate complexity | Dermatology | 5-7% | Moderate complexity, procedure mix | Cardiology | 6-8% | High auth requirements, complex coding | Orthopedics | 6-8% | Surgical billing, implant tracking | Behavioral Health | 7-9% | Heavy auth, session-based billing | Pain Management | 7-10% | High denial rates, complex modifiers | Neurosurgery | 8-10% | High-value claims, complex coding Advantages: Incentives are aligned, the billing company earns more only when you earn more. There is no upfront cost and no risk of paying for poor performance. This model is particularly attractive for practices with variable monthly volumes. Disadvantages: For high-revenue practices, the percentage can represent a significant dollar amount. A practice collecting $5M annually at 6% pays $300K in billing fees, which may exceed the cost of a well-run in-house billing team. 📥 FREE RESOURCE ### Use the ROI Calculator Punch in your monthly volume, collection rate, and denial rate, see exactly what outsourcing to Revenue Synergy would save (or earn) your practice in year one. Open Calculator → ## Why does outsourcing pricing differ so much by specialty? The 4-10% range is wide because the labor behind each claim varies enormously by specialty. Percentage pricing is, at its core, a proxy for the work required to collect a dollar. Five factors determine where a specialty lands in the range: Claim value relative to claim volume. A biller spends roughly the same effort submitting and following up on a $90 claim as a $9,000 claim. Specialties built on many small claims carry more labor per dollar collected, which pushes the percentage up. Prior authorization burden. Every service that requires an authorization adds intake work, payer phone time, and denial risk before the claim is even created. Coding and documentation complexity. Multi-procedure claims, modifier-heavy coding, and payer-specific bundling edits require certified coders to review claims individually instead of letting them flow straight through. Denial exposure. Specialties with high baseline denial rates require more appeal work per collected dollar, and appeals are the most labor-intensive part of billing. Payer mix. Heavy Medicare Advantage, Medicaid, or workers' comp exposure means more plan-specific rules and longer follow-up cycles regardless of specialty. ### Behavioral Health: Why It Prices in the 7-9% Band Behavioral health is the clearest example of the volume-to-value problem. A therapy practice generates a large number of low-dollar, session-based claims, and each one carries the same fixed handling cost. Add heavy authorization requirements, session frequency limits that payers enforce aggressively, and medical-necessity documentation reviews, and the labor per collected dollar is among the highest of any outpatient specialty. That is why behavioral health sits toward the upper part of the range even though the coding itself is not especially complex. ### Cardiology: Why It Prices in the 6-8% Band Cardiology combines complex procedural coding (catheterizations, electrophysiology, device implants) with a heavy prior authorization load on imaging and interventional work. What keeps it out of the top band is claim value: cardiology claims average much higher dollar amounts than behavioral health sessions, so the billing labor is spread across more revenue. Practices with a large diagnostic testing component tend to land lower in the band; intervention-heavy practices with more auth and appeal work land higher. ### ASC: Why Surgery Centers Price at the Upper End Ambulatory surgery centers submit fewer claims than office-based practices, but each claim is a project: multiple procedures on one claim, implant and invoice documentation, payer-specific grouper and bundling rules, and high dollar values where a single coding error can cost thousands. ASC billing also demands coders trained specifically in facility billing, which is a scarcer skill set. The result is upper-band pricing driven by per-claim effort and the cost of errors, not claim volume. Treat these as factors, not fixed price points. Two practices in the same specialty can land at different points in the band based on volume, payer mix, current clean claim rate, and scope of services. That is also why any quote given before a billing company has seen your data should be treated as provisional. ## What is per-claim medical billing pricing? Per-claim pricing charges a flat fee for each claim processed, regardless of the claim value. Rates typically range from $4 to $8 per claim, depending on specialty complexity and services included. | Monthly Claims | Per-Claim Rate | Monthly Cost | Annual Cost | 500 | $6.00 | $3,000 | $36,000 | 1,000 | $5.50 | $5,500 | $66,000 | 2,000 | $5.00 | $10,000 | $120,000 | 5,000 | $4.50 | $22,500 | $270,000 Advantages: Costs are predictable and easy to budget. For practices with high average claim values (surgical specialties, for example), per-claim pricing is often cheaper than a percentage model. A $2,000 average claim at $5 per claim is effectively a 0.25% rate. Disadvantages: The billing company has no financial incentive to maximize collection on each claim. They earn the same $5 whether the claim pays $50 or $5,000. This misalignment can lead to less aggressive follow-up on partially paid or underpaid claims. Want to see real numbers for your practice? Use our ROI Calculator to compare your current billing costs against outsourcing and see your projected savings. Calculate Your ROI → ## What is the per-FTE staffing pricing model? The per-FTE model charges a monthly fee for each dedicated billing staff member assigned to your account. Rates range from $2,000 to $4,000 per month per FTE, depending on the skill level required and whether the staff are domestic or offshore. Advantages: You get dedicated resources at a fraction of the cost of hiring employees (no benefits, no training costs, no overhead). This model works well for large practices or groups that need predictable staffing. Disadvantages: You are paying for bodies, not outcomes. There is no performance incentive built into the model. You also need to manage the team more actively, which partially defeats the purpose of outsourcing. This model is most common for large hospital systems or practice groups with strong internal RCM leadership. ## What hidden medical billing costs should you watch for? Regardless of the pricing model, some billing companies add fees that are not immediately obvious in the initial proposal. Ask specifically about each of these: Setup and implementation fees: $2,000-$10,000. Some companies charge for initial system configuration, data migration, and onboarding. A reasonable setup fee is $2,000-$5,000. Anything above that should be scrutinized. Clearinghouse and claims transmission fees: $0.25-$0.50 per claim. Some billing companies pass through clearinghouse fees separately. For a practice submitting 1,500 claims per month, that is an additional $375-$750 per month. Patient statement fees: $0.50-$2.00 per statement. Printing and mailing patient statements costs money. Some companies include it, others charge separately. At $1.50 per statement and 500 statements per month, that is $750 per month. Credentialing fees: $150-$500 per provider per payer. If your outsourced billing partner handles credentialing, they may charge per enrollment, separate from the standard CAQH ProView attestation. For a new provider being credentialed with 15 payers, that is $2,250-$7,500. Early termination fees: 2-6 months of average fees. Some contracts include steep penalties for early cancellation. Understand the exact terms before signing. Technology platform fees: $200-$1,000 per month. Some companies charge for access to their reporting dashboard or practice management system. This should be included in the base fee, push back if it is not. Module and add-on upcharges: Watch for proposals where eligibility verification, denial analytics, underpayment review, or patient payment tools are quoted as separate "modules" on top of the base rate. A 5% headline rate with three required add-ons is not a 5% rate. Ask for one all-inclusive number that covers billing, coding, AR follow-up, denial management, patient statements, and reporting. The simplest defense against all of these: request a complete fee schedule in writing before signing, and ask the company to confirm in writing that there are no charges beyond what is listed. A reputable billing partner will not hesitate. One that stalls on this question is telling you something. ## Is in-house or outsourced medical billing cheaper? The table below compares all-in costs for a typical 5-provider practice collecting $2.5M annually: | Cost Category | In-House | Outsourced (6%) | Billing staff (2 FTE) | $95,000 | Included | Benefits (health, PTO, taxes) | $28,500 | Included | Billing software licenses | $12,000 | Included | Clearinghouse fees | $6,000 | Included | Statement printing/mailing | $9,000 | Included | Training and CE | $3,000 | Included | Management oversight (10% of admin time) | $15,000 | $5,000 | Office space and equipment | $8,000 | $0 | Outsourcing fee (6% of $2.5M) | N/A | $150,000 | Total Annual Cost | $176,500 | $155,000 | Cost as % of Collections | 7.1% | 6.2% The direct cost savings in this example are approximately $21,500 per year. But the real value comes from improved collections. If outsourcing improves net collections by even 10% (conservative for most practices), that is an additional $250K in revenue, making the total benefit $271,500 against $155K in outsourcing costs. Important note: The in-house cost above assumes your billing team stays fully staffed. When you factor in the $4,000-$7,000 cost of replacing a biller who leaves, plus 2-3 months of reduced productivity during the new hire's ramp-up, in-house costs often run 15-25% higher than the base calculation suggests. ### The Line-Item Version of the Same Calculation If you want to build this comparison for your own practice, the line items matter. In our full in-house vs outsourced billing comparison , we itemize the same 5-provider, $2.5M family medicine practice in detail: a lead biller at $52,000, a billing assistant at $40,000, benefits at 30% of salary ($27,600), billing software at $9,600, clearinghouse fees at $8,400 (2,000 claims per month at $0.35), statement printing at $7,200, training at $2,400, office space and equipment at $8,000, administrator oversight at $13,500, and amortized recruiting costs at $3,000. That detailed build comes to $171,700 per year, or 6.9% of collections , for in-house billing. The same practice outsourced at a negotiated 5.5% rate pays $137,500 plus about $4,500 in remaining internal oversight, a total of $142,000, or 5.7% of collections . Direct savings: $29,700 per year. Then the revenue side: if the practice's denial rate drops from 10% to 5% and AR falls from 42 days to 28 days after outsourcing, the combined effect of fewer write-offs, faster collections, and recovered underpayments is roughly $250,000-$325,000 in additional annual revenue. Total first-year benefit of $280,000-$355,000 against $142,000 in fees works out to a 2:1 to 2.5:1 ROI, consistent with the simpler table above. The exact rate you negotiate moves the math at the margin; the structure of the result does not change. ## How do you calculate medical billing ROI? Use this framework to estimate your specific ROI from outsourcing: Step 1: Calculate your current all-in billing cost. Add every cost listed in the in-house column above that applies to your practice. Most practices underestimate this number by 20-30% because they forget to include benefits, management time, and overhead. Step 2: Get outsourcing quotes. Request proposals from at least 3 billing companies. Ensure each quote includes all fees, base rate, setup, clearinghouse, statements, and any other charges. Convert all pricing to a total annual cost for comparison. Step 3: Estimate the revenue improvement. Ask each billing company for their average collection improvement for practices in your specialty. Use the most conservative estimate. For a baseline, assume a 10% improvement in net collections, this is below what most practices experience but provides a conservative ROI estimate. Step 4: Calculate net benefit. Net benefit = (current in-house cost - outsourcing cost) + (estimated revenue improvement). Divide the net benefit by the outsourcing cost to get your ROI ratio. A 2:1 ratio or higher indicates outsourcing is a strong financial decision. For a more precise estimate, use our ROI Calculator which factors in your specific specialty, claim volume, current denial rate, and payer mix. ## What factors affect your medical billing price? Six factors influence where your outsourcing rate will fall within the ranges above: Specialty complexity. Specialties with complex coding, heavy authorization requirements, or high denial rates cost more to bill. This is not a markup, it reflects the additional expertise and effort required per claim. Monthly claim volume. Higher volume means lower per-unit cost. A practice submitting 5,000 claims per month will get a better rate than one submitting 500, because the billing company can spread fixed costs across more claims. Payer mix. A practice with 80% commercial insurance is easier and cheaper to bill than one with 60% Medicare/Medicaid and 20% workers comp. Government payers have more complex rules, lower reimbursement, and longer payment cycles. Current clean claim rate. If your current billing process is generating a 75% clean claim rate, the billing company will need to do more work to clean up your claims, which may justify a higher rate during the first 6-12 months. Scope of services. Full-service billing (registration through final collection) costs more than partial outsourcing (claims submission and follow-up only). The scope should match your actual needs, do not pay for services you do not need. Contract length. Some companies offer lower rates for longer commitments. Be cautious here, a lower rate is not worth being locked into a 3-year contract with a company that underperforms. ## When does outsourcing NOT make sense? Outsourcing is the right financial answer for most practices, but not all of them. Be honest about whether any of these describe you before requesting quotes: You are a large group (20+ providers) with strong RCM leadership already in place. At that scale, a well-run internal billing department with a dedicated manager, certified coders, and modern technology can approach outsourcing economics. The cost case for switching is weaker, though it should still be tested against actual quotes. Your revenue problem is upstream of billing. If denials are driven by front-desk eligibility errors, missing authorizations, or provider documentation gaps, outsourcing claim submission alone will not fix the root cause. A good billing partner will help address these, but only if the engagement scope includes front-end work. You have no one to own the vendor relationship. Outsourcing reduces management burden, it does not eliminate it. Someone in your practice needs to review monthly KPI reports, attend performance reviews, and escalate issues. If no one will do that, performance drifts regardless of vendor quality. Your billing workflows are inseparable from clinical operations. Clinical research billing, where charge capture is tied to protocol compliance, is the classic example. Deeply integrated workflows can make a clean handoff impractical. You are choosing on price alone. If the only quote you will accept is the cheapest one, you are likely to end up with a high-volume, low-touch vendor and worse net collections than you have today. In that case, fixing your in-house process may be the safer move until you can evaluate partners on performance. If none of these apply, run the numbers through the ROI Calculator and let the math decide. ## The Bottom Line Medical billing outsourcing costs less than in-house billing for the vast majority of practices, and delivers better financial results. The key is understanding the true all-in cost of your current billing operation (which most practices underestimate), getting transparent pricing from reputable billing companies, and calculating the ROI based on both cost savings and revenue improvement. Do not make this decision on cost alone. The cheapest billing company is rarely the best value. A company charging 7% that achieves a 99% clean claim rate and 24-day AR (as defined by HFMA's MAP Keys ) will generate far more net revenue than a company charging 4% with an 88% clean claim rate and 45-day AR. Related: Medical Billing Outsourcing Guide · ROI Calculator · Contact Us Get a transparent pricing proposal. Revenue Synergy provides clear, all-inclusive pricing with no hidden fees. Schedule a free revenue audit to get a custom proposal based on your specialty, volume, and current billing performance. ## Related Articles Revenue Cycle Management ### In-House vs Outsourced Billing: Cost Comparison Revenue Cycle Management ### Medical Billing Outsourcing: Complete 2026 Guide Revenue Cycle Management ### How to Choose an RCM Company in 2026 ======================================================================== # Revenue Synergy Pricing Source: https://www.revenuesynergy.com/pricing.html ======================================================================== Home / Pricing Transparent Pricing # Transparent # Medical Billing Pricing No hidden fees, no module upcharges. Revenue Synergy prices at 4-10% of collections based on specialty, volume, and complexity, fully inclusive of billing, coding, AR, denial management, patient statements, and reporting. 4-10% of Collections $0 Setup Fees 6 Performance Standards Book a 15-Min Pricing Call Get Your Custom Quote Pricing Models Explained ## 4 RCM Pricing Models, Which Is Right for You? The RCM industry prices services through four main models. Each has trade-offs. We lead with % of collections because it aligns incentives, we only make money when you do, but we'll structure the right model for your situation. ### % of Collections (4-10%) You pay a percentage of the revenue we actually collect. Aligns incentives perfectly, the vendor only gets paid when you get paid. Industry-standard range is 4-10% depending on specialty and volume. Our typical range: 6-7% for mid-market multi-specialty groups. ### Per-Claim ($4-12 per claim) Fixed fee per claim submitted. Can look cheaper on simple clean claims but misaligns incentives, the vendor is paid whether the claim collects or not. Works for high-volume, low-complexity specialties with stable payer mix. ### Per-FTE ($12-18/hr loaded) Dedicated full-time equivalents priced hourly or monthly. Best for staff augmentation, specific function outsourcing (AR only, denial management only), or large practices that want allocated dedicated capacity rather than shared-services coverage. ### Hybrid (Base + %) Fixed monthly base (covering infrastructure, account management) plus a smaller % of collections. Used for large practices with stable volume that want predictable budgeting, with upside sharing when collections grow. What Drives Your Rate ## Factors That Affect Your Percentage ### Specialty Complexity Oncology, cardiology surgical, ASC, and multi-modality practices typically price at the higher end (7-10%) due to coding complexity and payer-specific rules. Primary care, behavioral health, and straightforward outpatient specialties typically price at the lower end (4-6%). ### Monthly Claim Volume Higher volume earns a lower percentage, a 20-provider multispecialty group operates at a better rate than a solo practice because fixed operational overhead is spread across more claims. Economies of scale flow through transparently. ### Payer Mix Complexity Practices with heavy commercial plan exposure, workers' comp, auto no-fault, or complex capitation arrangements require more specialized AR work. Medicare-heavy practices with clean payer mix typically price lower. ### Legacy AR Condition Practices inheriting us with clean AR (under 35 days) price at the lower end. Practices with aged AR over 90 days typically require initial cleanup projects that are scoped separately, then transition to standard pricing. ### Scope Full RCM (coding through collections) is the standard quote. Some clients engage us for specific modules (AR only, denial management only, underpayment recovery only) which are priced differently, usually per-FTE or project-based. Typical Practice Scenarios ## What Practices Like Yours Actually Pay Illustrative monthly ranges based on representative client profiles. Your actual quote depends on specialty mix, payer mix, and current AR condition. ### Solo Practice $3,000 - $5,000/mo Single-provider practice collecting $500K-$800K annually. Typical specialty: primary care, behavioral health, derm. Standard scope: full RCM with credentialing maintenance. Pricing tier: 7-8% of collections. ### 5-Provider Group $12,000 - $18,000/mo Mid-size specialty or multi-specialty group collecting $2.5M-$4M annually. Full RCM including patient statements and underpayment recovery. Pricing tier: 5-6% of collections based on specialty mix. ### 20-Provider Multispecialty $40,000 - $60,000/mo Mid-market multispecialty group collecting $10M-$15M annually. Full RCM with dedicated pod, weekly leadership reviews, and quarterly strategy sessions. Pricing tier: 4-5% of collections due to volume. All-Inclusive Pricing ## What's ## Included ## in Our Fee Our percentage is fully inclusive. There are no module upcharges, no separate billing for denial management, no hidden fees for patient statements or underpayment recovery. What we quote is what you pay. Coding review and CPT/ICD-10 validation Charge entry and claim submission Clearinghouse fees and EDI enrollment Payment posting (ERA auto-post and manual EOB) AR follow-up at payer-specific milestones Denial management and appeals Underpayment detection and recovery Patient statements and payment portal Patient billing support calls Credentialing maintenance and CAQH updates Monthly reporting and KPI dashboards Named account manager and dedicated pod Quarterly strategy reviews with pod lead RevSyn AI layer (eligibility, denial prediction, posting) Get Your Custom Quote (15 min) $0 Hidden Fees 100% Transparent Pricing Industry Benchmarks ## Revenue Synergy vs Industry vs In-House | Cost Category | Revenue Synergy | Industry Average | In-House TCO | % of Collections | 4-10% | 6-12% | 8-12% (all-in) | Setup Fees | $0 | $2-15K typical | Recruiting costs | Clean Claim Rate | 99% | 90-95% | 88-93% | Days in AR | 24 | 38-42 | 38-45 | Contract Term | Straightforward, tailored terms | 2-5 years | Ongoing | Onboarding Time | 30-45 days | 60-120 days | 3-6 month hire | Module Upcharges | None | Common | Software/licensing Industry averages sourced from MGMA and HFMA benchmarks. In-house TCO assumes fully loaded salaries, benefits, software, turnover, and overhead. Next Step ## Get Your ## Custom Quote ## in 15 Minutes A short 15-minute conversation with our team is all we need to return a scoped quote within 2 business days. We'll review your specialty mix, monthly volume, payer mix, current AR condition, and PM/EHR environment, then quote a specific percentage with expected KPI commitments. 15-minute discovery call Custom quote within 2 business days Monthly performance scorecard included No obligation, no sales pressure Six performance standards Get Your Custom Quote (15 min) 15 min To a Custom Quote 2 days Turnaround Time 99% Clean Claim Rate 24 Days Average AR 500+ Providers $500M+ Recovered Related Resources In-House vs Outsourced TCO vs Mid-Market RCM Firms vs Enterprise BPO RCM Enterprise RCM Alternative Clearinghouse-Led RCM Alternative Contact FAQ ## Pricing FAQ What is Revenue Synergy's pricing model? Revenue Synergy charges a percentage of collections ranging from 4% to 10%, depending on specialty, volume, complexity, and scope. There are no hidden fees, our percentage is inclusive of billing, coding, AR follow-up, denial management, patient statements, underpayment recovery, and reporting. Setup and onboarding are included at no extra cost. What factors affect the percentage? Specialty complexity (oncology, cardiology surgical, ASC typically priced higher; primary care and behavioral health typically lower), monthly claim volume (higher volume earns lower percentage), payer mix complexity, in-flight AR condition, and scope (full RCM vs specific modules). Do you have setup or implementation fees? No. Standard onboarding (30-45 days with parallel-run transition) is included in the percentage. If your engagement requires extensive historical AR cleanup or custom integrations beyond standard PM/EHR access, those are scoped separately and quoted up front. You'll never see a surprise charge. What's included in the fee? Claim submission, coding review, charge entry, payment posting, AR follow-up, denial management, appeals, underpayment recovery, patient statements, patient support calls, credentialing maintenance, monthly reporting, real-time dashboard access, and a named account manager. No module-based upcharges. How does % of collections compare to per-claim pricing? Per-claim pricing (typically $4-12 per claim) can look cheaper on simple, clean claims but aligns incentives poorly, the vendor gets paid whether the claim is collected or not. % of collections aligns incentives perfectly: we only make money when you collect money. That means every denial, appeal, and underpayment is worked because it directly affects our revenue too. Is there a minimum commitment? We work with practices of every size, from solo providers through mid-size hospitals, and engagement terms are straightforward and tailored to your practice during the discovery call. We hold ourselves to six performance standards, including clean claim rate, days in AR, net collection rate, and denial rate, with targets calibrated to your practice during onboarding and tracked on a monthly scorecard you can review. Can I get a custom quote? Yes. A 15-minute call with our team produces a scoped quote within 2 business days. We review your specialty mix, monthly volume, payer mix, current AR, and PM/EHR environment, then return a specific percentage and expected KPI commitments. No obligation. Do you offer per-FTE or retainer models? We can structure per-FTE engagements for dedicated-staff augmentation scenarios (typically for larger practices or specific function outsourcing). These are priced at $12-18/hour fully loaded depending on credentials and skillset. Most clients prefer % of collections because incentives align better and the all-inclusive nature simplifies budgeting. ======================================================================== # Our Performance Standards Source: https://www.revenuesynergy.com/performance-standards.html ======================================================================== Home / Performance Standards Accountability You Can Measure # Our # Performance Standards Every Revenue Synergy engagement is measured against six KPIs, baselined to your own data, tracked in a dashboard you can open any time, and scored on a monthly scorecard reviewed with our operations leadership. No vague promises. Real numbers, measured in production. 6 KPIs Tracked Per Client Monthly KPI Scorecard Reviews 24/7 Live Dashboard Access Book Your Free Revenue Audit Talk to a Strategist Why We Publish These ## Numbers You Can Check, Not ## Marketing Claims Most RCM vendors describe their performance in pitch decks and never show you the numbers again. When performance slips, there is nothing to point to and no process for fixing it. We took a different path. We invested in dedicated pods, AI-assisted scrubbing, specialty-trained coders, and an independent quality assurance team that audits production work on a sampling schedule. Because the delivery model is measured continuously, we can afford to show you the numbers every month. For every client, we track the six KPIs below with specific numeric targets calibrated to your specialty and baseline. You see the same scorecard we do, every month. Every KPI target is calibrated to your baseline during onboarding Monthly scorecards with the raw data behind each metric Missed metrics trigger a documented corrective action plan You retain full ownership of data, workflows, and analytics See How We Measure Performance 6 KPIs Tracked For Every Client Monthly Scorecard You Can Audit What Gets Measured ## The Six KPIs We Commit To A standard is only as real as the numbers behind it. These are the six KPIs we hold ourselves to, baselined against your data during onboarding and scored every month. ### 1. Clean Claim Rate ≥ 99% First-pass acceptance across all payers, measured at the clearinghouse. Our multi-layer scrubbing catches demographic mismatches, NCCI conflicts, modifier issues, and payer-specific formatting errors before submission. ### 2. Average AR Days < 28 Average age of outstanding receivables across all payer classes. 28 days is our internal ceiling, not the goal: our clients average 24 days. Anything over 28 days signals either clean claim issues upstream or AR follow-up slippage, both inside our ownership. ### 3. Denial Rate < 5% Initial denials as a percentage of total submitted claims. Our AI denial predictor flags high-risk claims pre-submission; our denial team resolves and appeals anything that slips through within defined turn times. ### 4. Net Collection Rate ≥ Industry Benchmark Your specialty's MGMA and HFMA benchmark is the floor. We target 97%+ for most specialties and calibrate against your baseline data pulled in onboarding week one. ### 5. Response SLAs on Provider Inquiries Same-business-day response to provider-office inquiries and 24-hour resolution on routine billing questions. Measured monthly against a transparent ticketing log that you can audit. ### 6. Client Satisfaction ≥ 8/10 A structured 30-day and 90-day CSAT survey scored by the practice administrator, lead biller, or CFO, then repeated quarterly. Satisfaction is tracked as a first-class KPI, not an afterthought. How It Works ## From Baseline to Scorecard in Four Steps Every step of the measurement process is transparent from day one. Here is exactly what happens. ### Step 1: Onboarding & KPI Baseline (Days 0-14) We pull your existing billing data, payer mix, and aging reports, benchmark them against your specialty's MGMA and HFMA medians, and set a specific numeric target for each of the six KPIs. You see every target and every baseline on the shared dashboard from day one. ### Step 2: Ramp & Measurement (Days 15-90) Your dedicated pod takes over billing, coding, AR, and denial workflows. Performance is tracked in a shared dashboard you can access 24/7. Weekly KPI check-ins with your account manager surface any drift early, while daily huddles inside our pod catch operational issues before they hit your numbers. ### Step 3: Day-90 KPI Report Card At day 90, we deliver a formal KPI report card signed by your account manager and our VP of Operations. Every KPI is scored against the target set at onboarding. You get the raw data, the interpretation, and a written attestation, and the monthly scorecard cadence continues from there. ### Step 4: Corrective Action & Continuous Improvement If any KPI drifts below target, a documented corrective action plan kicks in: root-cause analysis within 5 business days, a named remediation owner, a timeline, and weekly progress reviews until the metric is back on target. Quarterly business reviews keep targets calibrated as your practice grows. Quality Assurance ## An Independent QA Layer Behind Every Number The scorecard is only trustworthy if the work behind it is audited. Our quality assurance program operates independently of the production pods. ### Coding Audits CPC-certified QA auditors sample coded encounters on a fixed schedule and verify against a 98.5% accuracy standard. Findings feed coach-backs and specialty-specific training updates. ### Claims & Posting Reviews Pre-submission scrub rules are re-validated monthly against payer behavior, and payment posting is reconciled daily so underpayments and misapplied adjustments surface immediately. ### Process Governance HIPAA, ISO 27001, and HITRUST CSF controls govern how work is performed and audited across every facility. Security and quality reviews follow the same discipline as the financial KPIs. 99% Clean Claim Rate Standard <28 AR Days Standard <5% Denial Rate Standard 98.5% Coding Accuracy QA Standard FAQ ## Frequently Asked Questions Straight answers on how our performance standards work in practice. What are Revenue Synergy's performance standards? Six KPIs we track for every client: clean claim rate of 99% or higher, average AR days under 28 (clients average 24 days), denial rate under 5%, net collection rate at or above your specialty's industry benchmark, response SLAs on provider inquiries, and a client satisfaction score of 8/10 or higher. Targets are calibrated to your specialty during onboarding. How is performance measured and reported? Every KPI is baselined against your own billing data during onboarding, tracked in a shared dashboard you can access 24/7, and scored on a monthly KPI scorecard reviewed with your account manager. At day 90 you receive a formal report card signed by your account manager and our VP of Operations, and quarterly business reviews continue from there. What happens if a KPI is missed? A missed KPI triggers a documented corrective action plan: root-cause analysis within 5 business days, a named remediation owner, a timeline, and weekly progress reviews until the metric is back on target. Misses are never hidden, the scorecard shows the raw data behind every metric. How do you maintain quality at scale? A dedicated quality assurance team audits coding accuracy, claim scrubbing, and payment posting on a sampling schedule independent of the production pods. QA findings feed coach-backs and process updates, and coding accuracy is verified against a 98.5% standard. Are the KPI targets the same for every practice? No. Targets are calibrated to your specialty, payer mix, and baseline data pulled during onboarding. A behavioral health group with heavy auth requirements and a cardiology practice with device-intensive cath cases will not share identical targets, but both see their targets and baselines on the shared dashboard from day one. Can I see the underlying data behind the scorecard? Yes. You get 24/7 access to the live dashboard, the monthly scorecard includes the raw data behind every metric, and response SLAs are measured against a ticketing log you can audit. You retain full ownership of your data, reports, and analytics. ======================================================================== # RCM Glossary Source: https://www.revenuesynergy.com/glossary/index.html ======================================================================== Home / Glossary Reference # Medical Billing & # RCM Glossary Plain-English definitions for 50 of the most common terms in medical billing, coding, compliance, and revenue cycle management. Bookmark this page. A B C D E G H I L M N O P R T U # ## A ### ABN Advance Beneficiary Notice, Medicare notice given before a service CMS may deny as not covered. ### ANSI X12 EDI standard family defining HIPAA transaction formats like 837, 835, 270. ### APC Ambulatory Payment Classification, Medicare OPPS outpatient payment grouping. ## B ### BAA Business Associate Agreement, HIPAA contract between covered entities and PHI-handling vendors. ## C ### CAQH Council for Affordable Quality Healthcare, centralized credentialing data via CAQH ProView. ### CARC Claim Adjustment Reason Code, standardized code explaining why a claim was adjusted or denied. ### Clearinghouse Intermediary that translates, scrubs, and routes EDI transactions between providers and payers. ### CMS-1450 CMS designation for the UB-04 institutional claim form used by facilities. ### CMS-1500 Standard paper claim form used for professional (physician) services. ### COB Coordination of Benefits, determines payer order when a patient has multiple coverages. ### CPT Current Procedural Terminology, 5-digit AMA code set for reporting medical services. ## D ### DRG Diagnosis-Related Group, inpatient prospective payment classification. ## E ### EDI Electronic Data Interchange, structured electronic exchange of claims and other transactions. ### EFT Electronic Funds Transfer, direct-deposit payment mechanism used by payers to settle claims. ### EOB Explanation of Benefits, document sent to patient explaining claim adjudication. ### EOP Explanation of Payment, provider-facing remittance summary, often paired with ERA. ### ERA Electronic Remittance Advice, HIPAA 835 transaction with claim payment detail. ## G ### GPCI Geographic Practice Cost Index, regional adjustment applied to RVUs. ## H ### HCPCS Healthcare Common Procedure Coding System, CMS code set for supplies, DME, drugs. ### HIPAA Federal privacy and security standards for health data. ### HIPPS HIPPS codes, classification used in home health and SNF prospective payment. ### HITRUST Certifiable security framework commonly required in healthcare vendor contracts. ## I ### ICD-10 International Classification of Diseases, 10th Revision, diagnosis (CM) and inpatient procedure (PCS) code sets. ### IPPS Inpatient Prospective Payment System, Medicare DRG-based hospital inpatient payments. ## L ### LCD Local Coverage Determination, MAC-issued policy on Medicare coverage for a specific service. ## M ### MAC Medicare Administrative Contractor, private contractor that processes Medicare Part A/B claims. ### MDS Minimum Data Set, standardized SNF resident assessment driving PDPM payment. ### MPFS Medicare Physician Fee Schedule, annual CMS Part B physician services schedule. ### MS-DRG Medicare Severity DRG, reflects patient severity and comorbidities. ### MSP Medicare Secondary Payer, rules determining when Medicare pays secondary to other coverage. ## N ### NCCI National Correct Coding Initiative, CMS edits preventing improper code-pair billing. ### NCD National Coverage Determination, CMS-issued national Medicare coverage policy. ### NOA Notice of Admission, home health notification required for PDGM 30-day billing periods. ### NPI National Provider Identifier, 10-digit unique identifier for US healthcare providers. ## O ### OASIS Outcome and Assessment Information Set, CMS-required home health assessment. ### OPPS Outpatient Prospective Payment System, Medicare payment system for hospital outpatient. ## P ### PDGM Patient-Driven Groupings Model, Medicare home health payment model (2020+). ### PDPM Patient-Driven Payment Model, Medicare SNF payment model replacing RUG-IV. ### PHI Protected Health Information, individually identifiable health information under HIPAA. ### POS Place of Service, 2-digit claim field identifying where service was delivered. ## R ### RA Remittance Advice, general term for payer payment detail document (ERA or paper). ### RARC Remittance Advice Remark Code, supplementary detail on a CARC adjustment. ### RVU Relative Value Unit, Medicare physician fee schedule component. ## T ### TIN Tax Identification Number, IRS-issued identifier used on claims for payment routing. ### TPL Third Party Liability, non-Medicaid payer responsible for payment ahead of Medicaid. ## U ### UB-04 Uniform Bill 2004, institutional claim form used by hospitals, SNFs, and home health. ## # ### 270 / 271 HIPAA eligibility inquiry (270) and response (271) transactions. ### 276 / 277 HIPAA claim status inquiry (276) and response (277) transactions. ### 278 HIPAA prior authorization request and response transaction. ### 835 HIPAA EDI transaction carrying ERA claim payment and adjudication detail. ### 837 HIPAA EDI transaction for electronic claim submission (837P professional, 837I institutional). Detail pages for each term are published on a rolling basis; each entry above contains the core definition. ======================================================================== # Behavioral Health Billing Services (Hub + Subspecialties) Source: https://www.revenuesynergy.com/specialties/behavioral-health.html ======================================================================== Revenue Synergy provides specialized billing and RCM for the full behavioral health vertical, serving providers in all 50 US states: psychiatry, therapy and counseling, ABA therapy, substance use treatment, ADHD treatment, and behavioral health group practices. ## Why is behavioral health billing different? Behavioral health billing is authorization-heavy (initial auth plus concurrent reviews every 6-12 sessions), session-limited, credential-dependent (different rules for MD, PhD, LCSW, LPC, LMFT), and governed by the Mental Health Parity and Addiction Equity Act (MHPAEA). Insufficient documentation is the leading cause of behavioral health claim denials, and behavioral health denial rates average 15-25%, two to three times the medical-practice average. ## Key behavioral health results - 40% reduction in authorization-related denials for behavioral health clients - 96.8% net collection rate across the behavioral health client book - 24-day average AR for behavioral health clients - $42M+ recovered through parity-based appeals ## Subspecialty coverage - Psychiatry (https://www.revenuesynergy.com/specialties/psychiatry-billing.html): E/M plus psychotherapy add-on codes (90833/90836/90838), 90791/90792 evaluations, telepsychiatry POS/modifier compliance, TMS (90867-90869) and Spravato program billing, collaborative care (99492-99494). - Therapy & Counseling (https://www.revenuesynergy.com/specialties/therapy-counseling-billing.html): Time-based psychotherapy codes (90832/90834/90837), 90837 downcoding defense, family (90846/90847) and group (90853) therapy, Medicare enrollment for LPCs/LMFTs (allowed since January 2024), paneling and credentialing. - ABA Therapy (https://www.revenuesynergy.com/specialties/aba-therapy-billing.html): Adaptive behavior codes 97151-97158 billed in 15-minute units, hours-to-units authorization conversion (20 authorized hours/week = 80 units of 97153), payer-specific concurrent billing rules for 97153+97155, BCBA/BCaBA/RBT roster credentialing, state Medicaid and TRICARE Autism Care Demonstration billing. - Substance Use Treatment (https://www.revenuesynergy.com/specialties/substance-abuse-billing.html): Full ASAM continuum (detox, residential 3.1-3.7, PHP, IOP, outpatient MAT), pre-admission verification of benefits, concurrent utilization review every 5-7 days, out-of-network billing and single case agreements, 42 CFR Part 2 confidentiality compliance. - ADHD Treatment (https://www.revenuesynergy.com/specialties/adhd-billing.html): Psychological testing codes 96130-96138 and 96127 rating scales, stimulant pharmacy prior authorizations, telehealth controlled-substance compliance, recurring med-management billing (99213/99214). - Group Practices: multi-provider credentialing matrices, supervisory/associate-level billing, per-provider productivity and collections reporting. ## Behavioral health EHR integrations TherapyNotes, SimplePractice, Valant, Kipu Health, Sunwave, BestNotes, Alleva, CentralReach, Rethink Behavioral Health, Catalyst, Osmind, plus general platforms (athenahealth, AdvancedMD, eClinicalWorks).