Many New Yorkers depend on public health coverage. Over 40% are enrolled in programs like Medicaid, the Essential Plan (EP), or Child Health Plus. Another 18–19% rely on Medicare. Providers face a particularly challenging environment when dealing with medical billing. The combination of large patient volumes and stringent payer oversight creates an uphill battle related to processing claims.

Top 10 Medical Billing Companies in New York

To minimize the number of denied claims and stabilize revenue, many providers choose to outsource medical billing functions to professional billing companies. This ranking will cut through the noise by evaluating each of the companies on the list based on their verified clean claim rates, confirmed BBB accreditation, independently verified Google Business Profile and Trustpilot ratings, as well as documented client outcomes, rather than relying on the company’s self reported marketing claims. 

Nexus io

Maintaining an in-house billing team can drain your finances. Nexus io saves you from this problem by not only improving your revenue cycle but also by offering incredible savings. That’s why it is the first name on our “Best medical billing companies in New York” list.

Nexus io was established in 2015. The company’s artificial intelligence platform has been specifically designed for high-volume clinical environments in which claim accuracy and speed of submission have a direct impact on cash flow; therefore, by partnering with Nexus io, urgent care centers, family practice organizations, telehealth companies and multispecialty organizations throughout New York can expect to be able to consistently receive as much revenue as possible.

Nexus io maintains a 98% first-pass clean claim rate and a 97% collection ratio. New York practices typically see a 30% decrease in accounts receivable days and an average 20% increase in gross revenue within the first few months of partnership. Their AAPC-certified coders handle the full healthcare revenue cycle from insurance eligibility verification through denial management and AR recovery services, backed by real-time dashboards that give your practice administrators immediate visibility into every claim.

iRCM, Inc.

While iRCM is the second name on our list, it is one of the best local medical billing companies in New York. Located in Brooklyn, NY, this firm has incorporated AI technology into its array of services, including medical billing, credentialing, claim processing, denial management, and front office support. Led by CEO Ahmad Masoud, iRCM has worked with 350+ healthcare practices in New York City, serving over 32 specialties.

iRCM is rated 5 out of 5 on Google My Business through 181+ verified client reviews, one of the highest volumes of reviews of any local New York medical billing company—and is rated 4.7 out of 5 on Trustpilot based on 33 reviews. Clients consistently describe iRCM as a practice partner rather than a vendor, with reviewers citing a 20% revenue increase, around-the-clock responsiveness, and a team that resolves payer disputes that other billing companies write off.

HMS USA LLC

HMS prioritizes quality over everything. Operating out of Floral Park in Long Island, NY, they strive to ensure customer satisfaction through proactive billing, quicker reimbursements, and lower costs. It tailors services, including credentialing, coding, and full RCM across 38 specialties. HMS’s attention to detail regarding patient registration, verification, charge capturing, claim submissions and follow-ups are not only upto the mark but also meets all New York regulations. They consistently achieve a 97-99% clean claim rate (99% first-pass) and have experienced a 25% growth in revenues and reduced costs.

HMS USA LLC has grown since its 2010 founding into one of New York’s most financially established billing operations, reporting approximately $20 million in annual revenue. HMS has a rating of A+ on the BBB, since 2025. They hold a 4.9 out of 5-star rating on Google My Business based on 35 verified clients, and a 4.2 out of 5-star rating on Trustpilot. They only work with solo practitioners, small medical clinics, nursing practices, and home health agencies, and have a successful closure rate of 85% for denied claims.

WCH Service Bureau

WCH Service Bureau, founded in 2001, is one of the longest-operating and most credentialed medical billing companies in the tri-state New York area. WCH is a medical billing company with over two decades of experience. It has held an A+ rating from the BBB since 2021. The company offers medical billing, credentialing, auditing of charts, and medical software development. It serves private practices, hospitals, labs, imaging centers, and pharmacies. WCH operates in New York City, New Jersey, Connecticut, and beyond.

The company has a 4.9/5-star rating on both Google and Yelp, and clients frequently mention dependable payment processing and clear reporting. This rating is largely possible through the proprietary PMBOS platform developed by the company. WCH’s team of certified professional coders is a direct submitter of electronic claims for Medicare, Medicaid, Blue Cross Blue Shield and GHI. The in-house EHR system used by WCH is known as iSmart and operates on a true seamless interface with no need for a middleman.

Sunknowledge Services Inc.

Sunknowledge Services Inc. has operated as an American-owned and managed RCM company out of Manhattan since 2006, building nearly two decades of New York-market expertise. The company holds ISO 9001:2015 certification for Quality Management and ISO 27001:2022 certification for Information Security Management.

Additionally, Sunknowledge’s policies are fully compliant with HIPAA and HITECH regulations. The company achieves a 97% first-pass acceptance rate. It provides customized billing services for over 30 specialties including DME, cardiology, radiology, and urology. Sunknowledge also has an average Google My Business rating of 4.1 out of 5.

CureMD

CureMD, which was established by Javed Zahoor and Kamal Hashmat in 1997. It is one of the oldest health IT companies in New York and has extensive experience in helping medical practices operate. Their integrated platform employs cloud-based EHR, practice management, and RCM billing to eliminate errors that lead to claim failures.

CureMD averages a 4.3 out of 5 on Trustpilot based on 26 reviews, while on Google they average a 4.5 out of 5 based on over 50 verified clients. Many practices have reported at least a 10-15% increase in their revenue after using CureMD’s integrated billing model. Their AAPC and AHIMA-certified coders submit claims within 48 hours of receiving documentation, and their real-time reporting dashboards give you granular financial visibility by payer, specialty, and procedure.

SybridMD (MD Syhealth LLC)

SybridMD, operating as MD Syhealth LLC and headquartered in New York since 2009, serves over 100 practices across 22 states from its home market. The company scores a 4.3 out of 5 rating on Google My Business from 31 verified clients. The company covers 37 specialties, including cardiology, urology, psychiatry, podiatry, and dermatology, and follows a mixed onshore-offshore delivery model that keeps billing costs competitive without sacrificing accuracy.

SybridMD offers the most transparent pricing available in the New York market at 4.7% flat fee based on collection amounts. Their team’s combined experience in the field of medical coding and billing exceeds 50 years. They have a 30-day free trial, which allows you to evaluate their service without any obligation. Their 24/7 support is regularly cited in client feedback as a differentiator for practices.

Barbara Young Billing

Founded in 2003 with over 20 years of experience, Barbara Young specializes in surgical billing with AAPC-certified coders who can automatically identify and fix coding errors before submission, achieving a self-reported 100% first pass claim rate. Clients report reimbursements arriving within 7 to 14 days.

The company’s surgical billing accuracy earns a 5.0 out of 5 on Google from clients who describe the team as the most experienced and trusted billing partner on Staten Island. It is the only BBB-accredited medical billing company on Staten Island, the only Staten Island billing firm that is a certified AAPC member, and the only one to be certified as a Minority and Women-owned Business Enterprise (M/WBE) by the NYC Department of Small Business Services.

Core Med Billing Inc.

Core Med Billing Inc. is a BBB-accredited medical billing company holding a current A rating and representing one of the newer additions to New York City’s verified billing landscape. The company serves multi-specialty practices with a self-reported 98% clean claim rate and has built its Google My Business profile to a 5.0 out of 5 rating from clients.

Core Med Billing is a boutique operation that offers both the ease of access and local presence of a small business as well as the performance benchmarks of big national companies. This makes Core Med Billing ideal for solo providers or small group practices in the Brooklyn and Bay Ridge areas that need on-site billing assistance but do not have the expense of working with a large company.

Top Notch Billing & Management Services Inc.

Top Notch Billing & Management Services is one of the only New York medical billing companies that has built its entire service model around Chronic Care Management and Remote Patient Monitoring billing. These are two of the fastest-growing and highest-denial-risk revenue streams in primary care.

The company’s BBB (A+) rating shows that they are capable of handling claims within 48 hours after receipt of documentation. They secure a 4.8-star Yelp rating based on client reviews for their level of individualized support with billing issues. For New York practices expanding into CCM and RPM programs, where payer rules around CPT 99490, 99457, and 99458 generate regular documentation disputes, Top Notch’s specialized knowledge of those code sets is a direct revenue protector that general billing companies often cannot provide.

Which Medical Billing Company Is Actually Worth It in New York?

While New York has plenty of options in medical billing, with many companies purporting to be able to get you cash flow quickly, there are only a handful of companies that can actually do this year after year. The difference between these companies is that they have proof of their claims with verifiable results.

We have compiled our list of the top 10 medical billing companies in New York so you can compare them on price, expertise, what they specialize in, their certifications, and their real client reviews and determine which company is best for your practice.If you are considering outsource medical billing services, to Nexus io leads the pack with flexible, tech-smart solutions built for easy onboarding and maximum reimbursements. Call us today to schedule a consultation for free!

Under the 2026 CMS Physician Fee Schedule Final Rule, nursing home CPT codes are undergoing major payment changes.

CPT Code 99309 is one of the most commonly used for this specialty. There is a substantial difference in reimbursement for a nursing home visit, CPT Code 99309. The most commonly used nursing home visit CPT code is as follows: When billing under POS 31 (Skilled Nursing Facility), the provider will receive approximately 6% less reimbursement than when billing under POS 32 (Nursing Facility), which will have 10% more reimbursement for the same CPT code.

2026 updates to skilled nursing facility CPT codes include changes in dual conversion factors and practice expense methodology, which affect provider reimbursement. This guide includes comprehensive information regarding 2026 skilled nursing CPT codes with important changes to reimbursement and, therefore, billing compliance requirements.

Nursing Home CPT Codes Description:

Nursing home CPT codes represent the evaluation and management services that are performed related to the care of residents of skilled nursing facilities. When billing for nursing home visits, CPT nursing home visit codes are used because the regulatory environment for long-term care facilities is different from that of an office visit.

Medical necessity is a key component of a compliant CPT code for billing nursing home visits. Each service level billed must be appropriately supported by clinical documentation of the medical necessity needed to justify the service.

Nursing Home CPT Codes Quick Reference

CPT Code	Service Type	Time	Complexity	Use Case
99304	Initial Care	25 min	Low	Post-op recovery
99305	Initial Care	35 min	Moderate	Multiple chronic conditions
99306	Initial Care	50 min	High	Unstable admission
99307	Subsequent Care	10 min	Straightforward	Stable monitoring
99308	Subsequent Care	15 min	Low	Minor adjustments
99309	Subsequent Care	30 min	Moderate	Care plan changes
99310	Subsequent Care	45 min	High	Acute deterioration
99315	Discharge	≤30 min	N/A	Routine discharge
99316	Discharge	>30 min	N/A	Complex discharge
99318	Annual	Variable	Comprehensive	Yearly evaluation

Initial Nursing Facility Care Codes (99304-99306)

Initial nursing home visit CPT codes apply regardless of whether the patient is new or established with the billing provider. The initial visit must occur within 30 days of admission. Proper selection of the CPT code for nursing home visits requires matching documentation to complexity.

CPT Code 99304: Initial Nursing Facility Care, Low Complexity

CPT 99304 applies to initial nursing facility evaluations requiring straightforward medical decision-making. There should be enough documentation to support about 25 minutes of total time. Low complexity scenarios could include a patient who had surgery but is recovering well or receiving IV antibiotics for a short period of time and has no serious medical problems.

CPT Code 99305: Initial Nursing Facility Care, Moderate Complexity

CPT 99305 applies to initial assessments with moderate-complexity medical decision-making. There should be enough documentation to support about 35 minutes of total time. Typical scenarios include patients with congestive heart failure and diabetes mellitus requiring medication adjustments or patients transferred from acute care with multiple chronic conditions.

CPT Code 99306: Initial Nursing Facility Care, High Complexity

CPT 99306 applies to initial evaluations involving high-complexity medical decision-making. There should be enough documentation to support about 50 minutes of total time. High complexity scenarios could include patients with sepsis (a severe infection), new or recently occurring stroke, or end-stage renal disease who require complex medication management as well as very close monitoring.

Subsequent Nursing Facility Care Codes (99307-99310)

Subsequent nursing home CPT codes capture follow-up visits after initial assessment. These skilled nursing CPT codes represent the most frequently billed services in nursing facility settings. Each CPT for nursing home visit must reflect actual work performed during the encounter.

CPT Code 99307: Subsequent Nursing Facility Care, Straightforward Complexity

CPT 99307 applies to follow-up visits requiring straightforward medical decision-making. The medical decision-making requires documentation from the encounter totaling about ten (10) minutes. Applications include stable patients requiring routine monitoring without care plan modifications.

CPT Code 99308: Subsequent Nursing Facility Care, Low Complexity
CPT 99308 applies to subsequent visits with low-complexity medical decision-making. Documentation must support a total time of approximately fifteen (15) minutes for the visit. Patients with well-controlled hypertension or diabetes mellitus on a long-standing and stable regimen may qualify for this type of visit.

CPT Code 99309: Subsequent Nursing Facility Care, Moderate Complexity

CPT 99309 applies to follow-up visits requiring moderate-complexity medical decision-making. Documentation must support a total time of approximately thirty (30) minutes for the visit. Examples include patients with chronic kidney disease who need medication changes, dementia patients who exhibit behavioral changes, and heart failure patients who require diuretics to be titrated. CPT 99309 represents the most commonly billed nursing home visit CPT codes.

Code 99310: Subsequent Nursing Facility Care, High Complexity

CPT 99310 applies to subsequent visits involving high-complexity medical decision-making for medically unstable patients. For patients in nursing facilities with medical instability, documentation of approximately 45 minutes of total time must be included in the follow-up visit notes. Common diagnoses for patients with high-complexity follow-up care include acute respiratory failure, unknown source of sepsis, and atrial fibrillation with hemodynamic instability.

Discharge Day Management and Annual Assessment

These nursing home visit CPT codes capture physician work preparing patients for transition from nursing facilities. Time determines which CPT code for nursing home visit applies for discharge management.

CPT Code 99315: Nursing Facility Discharge Management, 30 Minutes or Less

CPT 99315 is for discharge day management that takes 30 minutes or less of the physician’s time. Documentation must include a summary of care rendered during the visit, plans for follow-up, and education for the caregiver on how to care for the patient once home from the nursing facility. The most common usage of CPT 99315 is related to routine discharges of patients from skilled nursing facilities to their homes or assisted living facilities.

CPT Code 99316: Nursing Facility Discharge Management, More Than 30 Minutes

CPT 99316 is for discharge day management that requires more than 30 minutes of the physician’s time. The documentation should include evidence of the complexities surrounding coordinating discharges that require more than the basic required elements, including but not limited to significant coordination of multiple providers, thorough medication reconciliations, and extensive family education and counseling.

CPT Code 99318: Annual Nursing Facility Assessment

CPT 99318 applies to comprehensive annual evaluations requiring detailed medical history review, complete physical examination, and care plan updates. This planned annual service differs from problem-based subsequent visits and may substitute for one federally mandated visit when requirements are met.

Documentation must demonstrate a systematic review of all chronic conditions, preventive health measures, and advance directives. This CPT code nursing home visit serves as the comprehensive yearly evaluation required by federal regulations.

Rehabilitation Services CPT Codes

Therapy services in a Skilled Nursing Facility are captured using specific CPT codes for each type of therapy (PT, OT, and ST). The CPT codes representing all Skilled Nursing services have been updated to reflect newer standards for therapy documentation for facility use, including skilled nursing CPT codes for 2026. To maintain compliance and optimize reimbursement, many providers depend on specialized rehab billing services to ensure accurate coding, documentation, and claim submission.

CPT 97161: Physical Therapy Evaluation, Low Complexity

CPT code 97161 reflects the initial evaluation for physical therapy with straightforward clinical presentation and minimal need for treatment planning.

CPT 97162: Physical Therapy Evaluation, Moderate Complexity

CPT code 97162 is used for physical therapy evaluations with a less stable clinical presentation and moderate need for ongoing assessment and treatment planning.

CPT 97163: Physical Therapy Evaluation, High Complexity

CPT 97163 is used for complex physical therapy evaluations with a high level of assessment required and extensive treatment planning for those patients with an unstable clinical presentation.

CPT 97164: Physical Therapy Re-evaluation

CPT 97164 is the code used to reflect the re-evaluation of an established patient who requires a modified plan of care.

CPT 97165: Occupational Therapy Evaluation, Low Complexity

CPT 97165 is the code used for the initial evaluation for occupational therapy with a straightforward functional assessment.

CPT 97166: Occupational Therapy Evaluation, Moderate Complexity

CPT 97166 is used for occupational therapy evaluations that require moderate functional assessments and activity analysis.

CPT 97167: Occupational Therapy Evaluation, High Complexity

CPT 97167 is used for complex occupational therapy evaluations that require extensive functional assessments and extensive intervention planning.

CPT 97168: Occupational Therapy Re-evaluation

CPT 97168 is used for the re-evaluation of an established patient with modified functional goals.

CPT 92521: Speech Therapy Evaluation

CPT 92521 is the code used for the evaluation of speech, language, voice, or communication.

CPT Code 92523: Speech Therapy Treatment, 15 Minutes

CPT 92523 applies to treatment sessions lasting 15 minutes addressing communication or swallowing disorders.

CPT Code 92524: Speech Therapy Treatment, Additional 15 Minutes

CPT 92524 captures each additional 15-minute increment beyond the first unit.

Therapy Services Time Requirements Table

Service Type	CPT Code Range	Time Unit	Billing Notes
PT Evaluation	97161-97164	Per session	Based on complexity, not time
OT Evaluation	97165-97168	Per session	Based on complexity, not time
Speech Evaluation	92521	Per session	Comprehensive assessment
Speech Treatment	92523-92524	15-minute units	Timed increments

Wound Care, Psychiatric, and Ancillary Services

Wound care requires extensive documentation for nursing homes using CPT code references. Accurate documentation and proper coding are essential for compliance and reimbursement, which is why many facilities rely on specialized wound care billing services to ensure claims are submitted correctly. Make sure that the correct modifiers are attached to wound care bills for nursing home visit billing purposes.

Debridement is performed based on the outcome of cleansing the area after washing out the dead tissue. This process allows white blood cells (WBCs) a better chance of coming into contact with bacteria that might be present, improving the healing environment without first drying the area.

CPT 97597 – Debridement of Wound Surfaces

CPT code 97597 represents either selective or non-selective debridement of the wound surface, with the requirement that the area debrided be documented in square centimeters (cm2).

CPT 97598 – Removal of Devitalized Tissue

A CPT code of 97598 represents removing devitalized tissue from a wound, and documentation must describe the length and width of the wound and how much tissue was excised.

CPT 97602 – Wound Care (Cleaning, Dressing Application, and Local Care)

What is billed pursuant to CPT code 97602 represents a non-debridement wound, including cleansing, local care, and/or dressing applied to the wound.

CPT 97605 – Application of Negative Pressure Wound Therapy (NPWT)

CPT code 97605 is used to capture the NPWT systems used in promoting wound healing.

Conclusion

Proper billing of nursing home using the appropriate nursing home CPT codes will lead to reimbursement based on medical need, as well as meeting federal standards. When billing for nursing home CPT codes the healthcare provider must have complete support documentation for medical necessity before selecting the CPT Code Nursing Home Visit. In addition to medical necessity, the healthcare provider must keep detailed documented time for each CPT Code for nursing home visits/services provided.

Nexus io specializes in Nursing Home Billing Services, providing a full-service revenue cycle management program to help optimize your reimbursement. The coding team at Nexus io is in tune with the 2026 changes to skilled nursing facility CPT codes. All CPT codes for nursing home visits will be verified against established criteria to ensure proper CPT Code Nursing Home Visit selection and appropriate modifier assignment.

The Centers for Medicare & Medicaid Services projects national healthcare expenditures grew 8.2% in 2024, yet hospitals face a troubling reality (AHA reports). Bad debt and charity care surged 32% from 2022 to 2025. This financial squeeze makes accounts receivable in healthcare management more critical than ever. A/R, or accounts receivable in healthcare, needs constant monitoring to avoid flushing rightful payments down the drain. 

This guide explores what Accounts Receivable in healthcare (A/R) is, clears the confusion between accounts payable and accounts receivable, discusses common challenges, and provides strategies to keep your days in A/R short for better financial health.

What is Accounts Receivable A/R in Medical Billing?

Accounts receivable in healthcare represent money owed to providers for services already delivered to patients. These outstanding balances originate from insurance companies, government payers like Medicare and Medicaid, and direct patient responsibilities. The moment a claim leaves your billing system or a patient statement prints, that amount enters your AR of your medical billing cycle.

Accounts receivable in healthcare is a financial indicator that allows providers to manage revenue streams for consistent cash flow. It represents uncollected but recognized revenue and is classified as a current asset. It is continually changing as providers add new services, while reimbursements, write-offs, and modifications are applied.

How Is Medical Accounts Receivable Unique?

Medical accounts receivable differs fundamentally from AR in other businesses. Healthcare providers deliver services first and pursue payment later sometimes months later. The involvement of third-party payers creates a triangular relationship: provider, patient, and insurance company. 

High-deductible health plans have transferred financial burden to patients. However, collection rates remain problematic, with providers struggling to collect even half of the amounts owed. Bad debt write-offs result in billions of dollars in losses each year. 

Healthcare receivables management must adhere to HIPAA, FDCPA principles, state legislation, and No Surprises Act restrictions. Medical AR loses collection probability faster than regular receivables, with claims older than 120 days showing significantly lower collection rate than newer claims.

Quick Facts: 

1. Bad debt write-offs totaled $17.4 billion in 2023 (Kodiak Solutions).
2. PMC research (2025) found 36 percent of U.S. households carry medical debt, with $194 billion in active collections. 
3. Regulatory requirements add burdens—healthcare receivables management must comply with HIPAA, FDCPA guidelines, and No Surprises Act provisions. 

Difference Between Accounts Receivable and Accounts Payable in Healthcare

Are you confused about the difference? Here’s a quick breakdown for healthier RCM.

	Accounts Payable	Accounts Receivable
Origin	Originates from purchasing goods/services on credit from suppliers, vendors, and other creditors	Originates from providing healthcare services to patients
Meaning	Money the healthcare facility owes to suppliers and vendors	Money patients or insurance companies owe to the practice
Classification	Classified as a current liability on the balance sheet	Classified as a current asset on the balance sheet
Types	Wages payable, interest payable, sales tax payable, trade payables, loans payable	Trade accounts receivable, notes receivable, insurance receivable, patient receivable
Offset Allowance	No offset against payables	May have offset against doubtful accounts (bad debt reserve)
Impact on Cash Flow	Results in a cash outflow on the cash flow statement	Results in cash inflow on the cash flow statement
Responsibility	The healthcare facility is responsible for payment	The patient or insurance payer is responsible for payment
Audits	Involves monitoring the general ledger, vendor invoices, purchase orders, payment approvals, and vendor statements	Includes overseeing doubtful accounts, invoices, cash receipts, general ledger, aging reports, insurance payments, and patient payments
Management Goal	Extend payment terms without damaging relationships; capture early-payment discounts; maintain strong vendor relations	Accelerate collections; minimize days in AR; reduce bad debt; maximize collection rates

Effective accounts receivable and collection for the medical practice accelerates cash inflow by reducing days in AR calculation for healthcare, minimizing bad debt, and maximizing collection rates.

Accounts Receivable Challenges in Healthcare

A/R is a key metric in the RCM process and comes with challenges. By managing it and keeping the days to a satisfactory number, practices can avoid bumpy roads ahead.

Insurance Claim Denials

Frequent claim denial by third-party and government payers delays payments and affects financial health. Payers reject claims due to missing information, late filing, duplicate submissions, coding errors, and lack of medical necessity.

Excessive Write-offs

Writing off unpaid charges is like leaving money on the table. If you unnecessarily write off payments recoverable through effective A/R management, you strain your revenue cycle. Your billing office must follow streamlined processes. Without stringent procedures, unnecessary write-offs become financial losses, leading to bad debts.

Slower Reimbursement and Patient Collections

Insurance companies often take 30-60 days to process claims due to administrative backlogs. The rise in patient responsibility requires practices to chase patients directly. Most patients struggle to understand their financial obligations. Practices must communicate transparently about charges from the beginning.

Disorganized Processes and Technology Gaps

Practices without structured workflows see denial rates 40% higher and bad debt write-offs that are double the industry average. Many organizations struggle with outdated technology, yet those implementing modern solutions report meaningful improvements.

How to Improve Healthcare Accounts Receivable?

Streamline Insurance Verification

To avoid greater claim denials, incorporate eligibility verification before patient contacts. Integrate your EHR system with a real-time eligibility tool and set up weekly batch-checking processes.

Payment Estimates and Up-front Collections

Charge patients up front to avoid accounts receivable completely. Send cost estimates before appointments to avoid post-appointment billing and speed up reimbursement. 

Proactively Track Claims

Regular tracking ensures financial stability. Monitor payer and patient trends to keep your A/R statistics strong. 

Automate Your Claim Process

Manual billing is time-consuming and error-prone. Automate claim scrubbing and submission to reduce mistakes, mitigate denials, and achieve faster reimbursements.

Pull AR Aging Reports

Industry experts advocate keeping Days in AR between 30 and 40 days. Use aging reports to discover bottlenecks that require attention. 

Follow Up Systematically

Establish clear workflows for claim submission, payment posting, denial identification, appeal processing, and patient billing to prevent aging into high-risk categories.

Hire Experienced Staff

Specialized expertise in ICD-10 coding or ICD-11 coding, payer requirements, and denial management becomes invaluable for effective AR management.

Ensure Regulatory Compliance

Maintain compliance with HIPAA, FDCPA, state legislation, and No Surprises Act provisions through frequent training and audits.

Conclusion

Managing accounts receivable in healthcare is crucial to your practice’s financial health and operational stability. Understanding A/R, continuously reviewing your metrics, and following the improvement strategies outlined above can help you maintain healthy cash flow and reduce bad debt.

Effective AR management necessitates ongoing monitoring of aging reports, rigorous follow-up on outstanding claims, and keeping up with payer obligations. When you keep your days in A/R low and respond quickly to denials, you may make more informed financial decisions for your clinic.

Many healthcare providers choose to outsource medical accounts receivable to professional companies such as Nexus io. When you delegate billing and collections to skilled professionals, your staff can focus on what matters most: providing exceptional patient care. Instead of spending valuable time following up on unpaid claims, the team can concentrate on patients,  while AR Recovery specialists handle your Accounts Receivable (AR) Recovery Services with precision and efficiency.

Effective medical billing is a core operational aspect for any healthcare practices financial success and stability. It ensures timely payments, reduces claim denials, minimizes compliance risks, and helps maintain a smooth patient experience. Yet many healthcare providers find themselves asking a tough, important question.

Should we manage our own in-house billing and administrative team, or outsource it to a professional medical billing company?

This blog can assist your practice in making an informed decision. We’ll explore the differences between in-house billing and outsourcing medical billing services, and break down the advantages and disadvantages of each. So, that you can know which approach aligns best with your practice’s needs, resources, and long-term goals.

What is In-House Medical Billing?

In-house medical billing refers to managing the medical billing process internally using your own administrative staff, team and billing systems. This includes:

• The practice handles all aspects of billing, from coding and claim submission to payment posting and denial follow-ups.
•  In-house staff manages patient balances, sends statements, addresses inquiries, and sets up payment plans.
• The practice ensures accurate reporting, financial oversight, and compliance with healthcare regulations.
• The practice retains full control over the entire billing process, allowing for personalized processes and direct oversight.

Pros and Cons of In-House Medical Billing

Pros	Cons
Full control over billing operations and immediate issue resolution.	Expensive to hire and maintain in-house billing staff.
Easier collaboration with clinicians and staff to reduce coding errors.	High turnover can disrupt billing operations.
Customizable reports, processes, and policies to fit practice needs.	Requires constant training and adjustments to keep up with changes in regulations.
Full control over patient data security.	High overhead due to staffing and software costs.

What is Outsourced Medical Billing?

Outsourced medical billing involves contracting a third-party medical billing company to handle some or all of your billing responsibilities. These companies usually specialize in revenue cycle management (RCM), practice management software (PMS), EHR/EMR and often serve multiple practices or specialties. As these practices totally rely on their professional expertise to process claims and facilitate reimbursement. How it works:

• Practice document patient encounters and share the data with the billing company through cloud-based integrated billing softwares. 
• The billing company ensures adherence to healthcare regulations (HIPAA, CMS guidelines), reducing legal risks and keeping your practice compliant with evolving standards.
• The company manages coding, claim submissions, payment posting, and denial follow-ups, and also provides advanced reporting systems. 
• You receive performance reports and updates, and retain visibility into the process via a client portal or dashboard.

Pros and Cons of Outsourced Medical Billing

Pros	Cons
Expert coders and billing professionals with up-to-date industrial expertise and knowledge.	Less direct control over billing workflows and decisions with communication barriers.
Frees up in-house staff to focus on patient care and other tasks.	Service quality may vary based on the vendor’s experience and technology.
Avoids fixed costs; only pay for services as needed.	Contracts may come with hidden fees that often go unnoticed
Easily scalable to accommodate practice growth or fluctuations.	Risk of data breaches when sharing sensitive patient information.

Key Factors in Choosing In-House vs. Outsourced Billing

Here are some factors you may consider when making an informed decision about whether to go with an in-house medical billing team or outsource the services to a third-party medical billing company:

1. Practice Size and Patient Volume

• Small Practice: Small practices often have limited resources. Hiring and retaining full-time, experienced billing staff may not be financially feasible. In these cases, outsourcing medical billing becomes a more practical option as it offers the flexibility to scale services as needed without the high overhead costs.

• Large or Multi-Specialty Practice: Larger practices or those with multiple specialties may benefit from having an in-house billing team. The variety of services and specialties requires an expert team that can handle diverse billing needs. In-house teams also have the advantage of greater flexibility in managing specific billing workflows related to high-complexity procedures, such as surgeries or diagnostic imaging.

2. Budget and Financial Resources

• Affordability of Hiring Billing Staff: The cost of hiring and retaining skilled billing professionals (including salaries, benefits, and software costs) can be prohibitive, especially for smaller practices. In-house billing may require significant financial resources to maintain full-time staff.

• Variable Cost Structure: Outsourcing medical billing company can provide a more cost-effective solution for smaller practices or those with variable cash flow. Instead of incurring fixed expenses like salaries, practices can choose a billing service that aligns with their volume, paying only for the services they need when they need them. This flexibility can ease financial strain, particularly for practices with fluctuating patient numbers.

3. Staffing Capabilities and Training Programs

• Access to Experienced Billing Professionals: In-house billing requires hiring professionals who are experienced in coding and billing procedures. Without access to certified professionals, practices risk billing errors, which can lead to claim denials, delayed payments, or penalties. If a practice lacks the resources to hire experienced coders, outsourcing may be a more viable option.

• Ongoing Training and Managing Turnover: In-house billing requires continuous training to stay up to date with ever-evolving regulations such as ICD-10 updates and payer-specific rules. Staff turnover can disrupt the process, potentially leading to delays or mistakes in billing. Outsourcing helps mitigate these challenges by providing specialized expertise without the need for ongoing training or managing high turnover.

4. Billing Complexity

• High Volume & Multiple Specialties: Practices with high patient volumes or those offering complex services (such as surgeries, specialty care, or diagnostic procedures) require an experienced billing team to handle the detailed and specialized coding that these services demand. In-house teams may be better equipped to customize workflows and ensure accuracy in these situations.

• Customization Needs: High-level services and multiple specialties often require customized billing workflows to ensure accurate coding, prevent errors, and avoid denials. While outsourcing might provide more standardized services, some outsourcing companies may offer tailored services. However, in-house teams can offer more direct control and customization for specific needs.

5. Compliance and Risk Tolerance

• Staying Updated with Regulations: Medical billing involves staying current with frequently changing payer rules, CMS guidelines, and coding standards. In-house teams must be proactive in adjusting their processes to meet these changes. Outsourcing to a reputable billing company can alleviate the burden of staying up-to-date with evolving regulations, as specialized billing companies are dedicated to maintaining compliance.

• Managing Audits and Denials: Handling audits, claim denials, and payment disputes is part of the billing process. Practices with in-house teams may have more direct control over these issues, but outsourcing can often result in quicker resolution of denials, as billing companies specialize in managing these challenges. Outsourcing also reduces the administrative burden on in-house staff, allowing them to focus on other aspects of the practice.

6. Scalability and Growth Plans

• Support for Practice Expansion: As a practice grows, it may need to scale its billing operations to accommodate more patients, services, or locations. In-house billing teams may require additional resources and infrastructure to keep up with growth, which can involve hiring more staff or investing in more complex software systems.

• Adapting to New Services: If your practice is adding new services (such as telehealth) or expanding into new locations, you need a billing system that can quickly adapt to these changes. Outsourcing allows for more flexibility, as billing companies can scale their services to fit the growing needs of your practice. This can be done without the overhead of hiring or retraining in-house staff. In-house teams may need more time to adjust to such changes, depending on the complexity of the new services offered.

Final Thoughts

Both in-house and outsourced billing come with trade-offs. The best decision depends on a detailed evaluation of your resources, growth plans, and risk appetite. In-house billing gives you full control but demands significant investment and ongoing effort. Outsourcing, on the other hand, reduces your workload and provides access to specialized expertise, but at the cost of some control.

Ultimately, the right billing model is the one that supports your practice’s revenue goals, ensures compliance, and allows your team to focus on what matters most patient care. Alternatively, you can outsource your medical billing services to Nexus IO to ensure timely reimbursements and faster payment collections.

Medical billing is a continuous process of evolving, and professionals face a range of billing and coding challenges to maintain a healthy cash flow. From ever-changing regulations to administrative overload, the obstacles can overwhelm even the most efficient practices. If not managed properly, these issues can result in claim denials, delayed payments, compliance risks, and ultimately lead to unsatisfied patient experience.

In this blog, we’ll look closely at the top 10 medical billing challenges and give you clear, actionable solutions to ease administrative burden, minimize claim denials, and maximize your revenue cycle overall. 

What are Common Medical Billing Challenges?

Medical billing is an essential function in every healthcare practice, but managing it efficiently can be challenging. Fortunately, a combination of modern technology and professional services can help ease the burden. Below are some of the most common medical billing challenges faced by U.S. healthcare providers today:

1. Complex and Ever-Changing Regulations

Healthcare regulations are constantly evolving and placing significant pressure on healthcare providers and their staffing. Every year brings changes to medical codes (ICD-10, CPT, HCPCS), payer requirements, and compliance mandates like HIPAA, CMS. With frequent changes in insurance policies related to reimbursement rules, the process demands a high level of accuracy. Additionally, maintaining security compliance with government laws and regulations further requires continuous adaptability.

Common issues include:

• Using outdated codes or billing formats.
• Violating new compliance rules unknowingly.
• Struggling with payer-specific billing requirements.
• Leaking patient data leading to potential penalties. 

Solution:

• Stay updated: Make sure to subscribe to industry newsletters, CMS updates, and payer bulletins, to keep your staff updated with all the changes. 
• Ongoing training: Schedule regular training sessions for billing and coding staff to keep them updated on policy changes and ensure compliance with the latest regulations.
• Technology: Use cloud-based billing software like a Practice Management System (PMS) that integrates with payer systems, allowing automatic updates with regulatory changes.
• Compliance support: Work with consultants or outsource billing to medical billing firms that specialize in up-to-date billing practices.
• Patient Data Leaks: Implement end-to-end encryption and strict access to your system control panels; regularly conduct audits for vulnerabilities and compliance. Moreover, train your billing staff on HIPAA regulations and establish clear protocols for data handling and breach response.

2. Coding Errors and Inaccuracies

Medical coding is the foundation of the billing process. A single wrong medical code or use of incorrect modifier, whether due to typo mistake, undercoding, or over coding can lead to claim denial, delayed reimbursements, or even legal compliance issues. These mistakes often result from outdated codebooks, lack of staff training, or human error, emphasizing the need for regular audits, updated resources, and staff education to ensure accurate and compliant billing practices.

Common causes of errors:

• Use of outdated sets of codes.
• Incorrect or missing modifiers.
• Lack of coder training or certification.
• Rushed data entry or human error.
• Poor documentation from clinicians.
  

Solution:

• Hire Certified Coders: Hiring or training staff with certifications like CPC (Certified Professional Coder), CCS (Certified Coding Specialist), or AAPC (American Academy of Professional Coders) to ensure accuracy and expertise in medical coding. Invest in comprehensive webinars and training sessions to keep your staff up-to-date with the latest coding guidelines and regulations. 
• Audit regularly: Implement and conduct random audits and quality assurance processes to identify issues and error trends before they escalate. Regular audits for your medical billing process also serve as internal keeping checks to maintain coding standards. 
• Use AI tools: Use AI-powered coding softwares that provide you with real-time coding assistance, compliance check, and suggest corrections in real-time. This reduces overall claim denials chances and enhances billing efficiency.
• Improve documentation: Foster collaboration with medical billers, coders, clinical staff to ensure their patient notes are always complete and up-dated with all the relevant required information. As clear documentation reduces ambiguity and supports a clean claim process. 

3. Claim Denials and Rejections

Claim denials and rejections is one of the common challenges in healthcare billing, where an insurance company either refuses to pay a claim or returns it to the provider for correction. Usually, payers reject claims for reasons like missing information, incorrect medical code, or no use of procedural modifier. The causes of these issues often include lack of proper clinical documentation, patient insurance eligibility problems (such as expired coverage), and missed filing deadlines. These factors can lead to claims being denied or delayed by payers, resulting in financial strain on the practice and contributing to accounts receivable (AR) problems.

Consequences:

• Delayed reimbursement.
• Lost revenue if not followed up promptly.
• Increased AR (Accounts Receivable) days.
  

Solution:

• Pre-submission checks: Utilize claim scrubbing software to catch coding, formatting, or data entry errors before submission. This reduces claim rejections and ensures faster, cleaner processing by payers.
• Denial management: Monitor denial trends regularly to identify common patterns and systemic issues. Address root causes with training or workflow adjustments to reduce future denials.
• Appeals process: Establish a specialized team or standardized process to handle denied claims swiftly. Ensure documentation and appeal letters are accurate, timely, and payer-compliant.
• Timely follow-up: Implement automated software tools to track claim statuses and flag pending actions. Set reminders for follow-up at key intervals to avoid missed deadlines or write-offs.

4. Administrative Burden

Manual data entry, completing forms, following-up claims, and verifying insurance are time-consuming tasks that place a heavy administrative workload on healthcare staff. These repetitive processes often require significant attention to detail and constant follow-up, diverting valuable time away from patient-facing responsibilities. As staff juggle multiple systems and paper-based workflows, errors are more likely to occur, leading to claim rejections, delayed reimbursements, and the need for rework—all of which further increase workloads. 

Why it’s a problem:

• High labor costs.
• Staff dissatisfaction and turnover.
• Reduced focus on patient care.
• Increased risk of errors and claim denials.
• Slower revenue cycle and cash flow delays.

Solution:

• Automate workflows: Implement automation tools to handle repetitive tasks such as insurance eligibility checks, claim submissions, and payment postings. This reduces errors, speeds up processes, and frees up staff to focus on higher-value work.
• Centralize information: Adopt an integrated platform that connects billing, electronic health records (EHR), and patient information in one system.
• Centralized data improves accuracy, enhances coordination, and allows faster decision-making.
• Reduce manual work: Outsource labor-intensive processes like coding, claims follow-up, or use PMS to handle routine data entry.This minimizes human error, lowers administrative burden, and increases operational efficiency.

5. Lack of Skilled Billing Staff

Hiring and retaining experienced billing professionals is becoming increasingly challenging, particularly for rural healthcare facilities and smaller medical practices. These organizations often struggle to compete with larger hospitals and urban health systems that can offer more attractive salaries, comprehensive benefits, and opportunities for career advancement. This shortage not only puts pressure on existing team members but also forces providers to spend valuable time training inexperienced hires, further disrupting productivity and impacting the overall financial health of the practice.

Issues this causes:

• Increased errors and slow claim cycles.
• Loss of institutional knowledge.
• Inconsistent cash flow.
• Compliance and audit risks.
• Dependence on a few key employees.

Solution:

• Invest in talent: Offer competitive salaries, flexible remote work options, and ongoing training to attract and retain skilled billing professionals. Supporting career growth helps build loyalty and reduce turnover.
  
• Cross-train staff:Train team members across multiple billing functions to ensure continuity in case of absences or departures. This builds operational resilience and reduces dependency on any one individual.
• Outsource when needed: Partner with a trusted medical billing company that provides access to certified experts, scalable support, and proven systems. Outsourcing can fill gaps quickly without sacrificing accuracy or compliance.

6. Patient Billing & Communication Issues

Many patients find medical bills confusing and difficult to interpret, which leads to frustration, delayed payments, and an overall negative experience with the healthcare provider. Often, bills arrive weeks after a visit with little explanation, leaving patients unsure of what services they’re being charged for, what their insurance covered, or why certain charges weren’t included in their plan. Without clear communication or easy access to billing support, patients may ignore or dispute their bills altogether. This not only delays revenue for the practice but can also damage patient trust and satisfaction.

The impact:

• Late or missed payments.
• Patient frustration and reduced loyalty.
• Decreased cash flow.
• Increased collection costs.

Solution:

• Transparent billing: Provide patients with itemized, easy-to-read bills that clearly outline each service and charge. Include a brief explanation of what was covered by insurance and any outstanding balances to reduce confusion.
• Digital tools: Implement online portals where patients can view their bills, make payments, and track insurance claims in real-time. This gives patients more control over their billing and streamlines payment processes for the practice.
• Clear communication: Train your staff to explain insurance coverage, co-pays, and expected charges before and after appointments. Setting clear expectations upfront minimizes misunderstandings and encourages timely payments.

7. Insurance Verification and Eligibility Errors

Failing to verify a patient’s insurance coverage before treatment is a common but costly mistake that can severely impact a practice’s revenue cycle. Without confirming insurance eligibility and benefits in advance, there’s a high risk that the insurer may deny the claim due to lack of coverage or preauthorization. This leaves the practice holding the bill for services rendered, which may not be fully recoverable. Worse, the patient, unaware of their insurance limitations, may not be willing or able to pay the full amount out of pocket.

This leads to:

• Revenue loss.
• Increased administrative costs.
• Unsatisfied and angry patients.
• Long reimbursement cycles.
• Payment clearance delays. 

Solution:

• Real-time Verification: Implement insurance verification software that checks eligibility and benefits instantly during the scheduling or check-in process. This ensures that both you and the patient are aware of their coverage before treatment begins, reducing the risk of claim denials.
• Confirm Coverage at Multiple Points: Verify insurance coverage during the scheduling process, again at check-in, and once more just before the appointment. This ensures you have the most up-to-date and accurate information, minimizing the chances of errors or surprises on the day of service.
• Keep Data Current: Regularly update patient information, including insurance details, addresses, and contact numbers, to maintain accurate records. This reduces the likelihood of processing errors and ensures claims are submitted correctly the first time, avoiding delays or denials.

8. Use of Advance Technology

Many healthcare practices continue to rely on outdated software, spreadsheets, or siloed systems that aren’t integrated, which can create significant operational inefficiencies. When different systems don’t “talk” to each other, data must often be entered manually into multiple platforms, leading to duplication of work and a higher risk of errors. For example, patient information may be incorrectly entered in one system and not updated in another, resulting in billing mistakes, claim denials, or delayed reimbursements. Additionally, the lack of seamless communication between systems causes slow processes, as staff members may need to spend extra time switching between applications, copying and pasting data, or reconciling discrepancies. 

Problems it creates:

• Poor visibility into revenue cycle metrics.
• Longer billing cycles.
• Difficulty in identifying bottlenecks.
•  Increased operational costs.
• Compliance risks.
• Increased manual work and error risk.

Solution:

• Advance RCM solution: Adopt cloud-based RCM platforms that streamline the revenue cycle with automated workflows, real-time dashboards, and advanced analytics. These tools help monitor key performance indicators (KPIs), track claim statuses, and identify trends, making it easier to optimize billing processes.
• System integration: Ensure seamless integration between your EHR, billing system, and patient engagement tools. This creates a unified workflow, reducing data entry errors, enhancing efficiency, and providing better insights for both patient care and financial management.
• Compliance: Invest in RCM solutions that are regularly updated to comply with ever-changing healthcare regulations. This ensures your practice stays aligned with billing standards, payer requirements, and government regulations, minimizing the risk of audits, penalties, or denials due to non-compliance.
• Training: Provide ongoing training for your staff to ensure they are proficient in using new RCM tools effectively. A well-trained team can maximize the potential of automation, reduce errors, and improve productivity, leading to higher returns on investment (ROI) from your technology.

9. Data Management and Quality Control

Accurate data is crucial to successful billing because even small errors can become a major issue, affecting both revenue and patient relationships. Simple mistakes such as misspelled names, incorrect or outdated information can cause insurance providers to deny claims outright or delay processing. These errors often lead to additional administrative work, as staff must spend time correcting and resubmitting claims. Furthermore, inaccurate data can create confusion for patients, leading to frustration and, in some cases, disputes over charges. 

Other issues include:

• Duplicate records.
• Inconsistent coding practices.
• Audits and costly penalties.
• Security and HIPAA violations due to poor data handling.

Solution:

• Data validation tools: Implement data validation tools that check for errors at the point of entry, such as incorrect patient information or missing fields. These tools help catch mistakes before they impact the billing process, reducing the risk of denials, delays, and costly penalties. 
• Quality control: Establish regular quality control processes to review claims and documentation for accuracy before submission. By regularly auditing claims, you can catch errors trends, ensuring that everything is correct and compliant with payer requirements.
• Secure systems: Adopt HIPAA-compliant platforms with built-in audit trails and access controls to ensure the security of patient data. These systems safeguard sensitive information, track who has accessed data, and protect against unauthorized changes or breaches.

10. Delayed Payments and Cash Flow Issues

Slow reimbursements from insurers and delayed patient payments can significantly strain a healthcare practice’s cash flow, and create some financial challenges as well. When claims take weeks or even months to be processed and reimbursed, it can leave the practice without the necessary funds to cover day-to-day operational costs, such as staff salaries, rent, utilities, and medical supplies. This delay can force practices to rely on credit lines or loans to stay afloat, which adds unnecessary interest expenses and financial stress. Similarly, if patients delay or fail to pay their bills, it compounds the problem. Uncollected patient balances create a backlog of unpaid invoices, leading to further cash flow problems and potential bad debt. As a result, practices may face difficulty managing their finances, affecting their ability to invest in new equipment, expand services, or even maintain essential staff. 

Signs of this issue:

• High days in A/R.
• Growing accounts receivable backlog.
• Slow cash flow.
• Strained operating budgets.

Solution:

• Flexible payment options: Offer online payment portals, payment plans, and automatic billing options to make it easier for patients to pay. These flexible options improve patient convenience and increase the likelihood of timely payments, reducing the risk of unpaid balances.
• Proactive collection: Collect copays and deductibles upfront during patient check-in or scheduling whenever possible. This reduces the chances of delayed payments and ensures that the practice receives payment for services rendered before the patient leaves.
• Cash flow tracking:Utilize dashboards and forecasting tools to track cash flow and identify potential revenue dips ahead of time. These tools allow you to plan accordingly, adjusting staffing or expenses to ensure financial stability during slower payment cycles.
• Outsourced collections: Partner with ethical, patient-friendly collection agencies if necessary to recover overdue balances. These agencies help recover payments while maintaining a positive relationship with patients, reducing the burden on in-house staff.

Final Thought

Medical billing doesn’t have to be a constant battle if healthcare organizations proactively address the challenges they face. By recognizing common issues as mentioned above practices can smooth down their billing process, with better cash flow, and increased patient and staff satisfaction. With advance and cloud-based technology driven solutions, healthcare organizations can tackle the complexities of medical billing and focus on what matters most: delivering high-quality care.

Otherwise, contact us today to learn how Nexus IO can help you streamline your medical billing process and overcome all these challenges by outsourcing your services to our expert team.