Revenue Cycle Management

AdvantEdge solutions include medical billing, certified coding, analytics,
practice management, compliance and ClientFirstTM service.

Revenue Cycle Management

AdvantEdge solutions include medical billing, certified coding, analytics, practice management, compliance and ClientFirstTM service.




5 Workflow Questions for Medical Billing Companies

For accurate medical coding, here are five technology-related questions to ask when assessing your medical billing department or your current/potential medical billing company. When it comes to medical coding, what you don’t ask about automated workflows and technology can hurt your bottom line! Read More

Healthcare Roundup

EFT | 2 min read

Are You Paying Too Much in EFT Fees?

Recent studies show that many practices are paying EFT fees they did not agree to, raising medical billing and payment costs. Are you paying too much?! Read More

Mental Health | 2 min read

Mental Health Parity in the News

While mental health parity often takes a back seat in behavioral health billing, recent news shows that it has not been forgotten. Read More

Healthcare | 2 min read

Healthcare Utilization Not Bouncing Back

Recent studies and data throw cold water on expectations that patients will “catch up” on missed treatment and tests. With the resurgence of COVID, this trend is likely to continue, impacting physician reimbursement.  Read More

CMS | 1 min read

Radiology Reimbursement Hit by 2022 MPFS Changes

Radiology reimbursement will be hit by proposed changes in the wages for clinical labor staff and by the elimination of important MIPS quality measures. Read More

COVID-19 | 1 min read

COVID Vaccine Shot Reimbursement Increased

CMS has updated Medicare Reimbursement for Covid vaccine shots including boosters to approx $40. Plus $35 for home administration. Read More

Lessons Learned: COVID’s Impact on Your Medical Billing

Have you thought about the need to consider the “lessons learned” from COVID? Download our NEW business brief to understand key elements your practice should consider as we shift (hopefully!) to a post-COVID world.


Practice Review Kit




Accurate medical coding is obviously essential to the medical billing process. But the critical role of technology in the coding process is easy to overlook. For hospital-based physicians, most of the information needed for billing exists in one or more systems: HIS, ADT, EMR, lab, CIS, etc. These systems are typically large, complex and customized. Therefore, sophisticated systems and workflows are needed to extract the information needed for medical coding and billing. 

For accurate medical coding, here are five technology-related questions to ask when assessing your medical billing department or your current/potential medical billing company. When it comes to medical coding, what you don’t ask about automated workflows and technology can hurt your bottom line!

     1. What would my automated workflow look like compared to my current one?

If you’re considering a new medical billing company, you want to fully understand the logistics of their proposed workflows. How would your current workflow be optimized? Is the company equipped to automate all current workflows?  What specific benefits do you have to gain? It’s wise to share your current workflow and request an outline showing how the new company would handle the process from start to finish. How would they enhance coding accuracy and efficiency – and payment turnaround times? You should see firsthand how an automated workflow would work and how it would create better outcomes for your practice. Get this visibility beforehand – not after you are converting and get surprised.

     2. Can you handle different types of workflows?

Make sure the medical billing company is in sync with your workflow regardless of what clinical information system, hospital information system or “bolt-on” technologies you are using today. Consider Pathology coding. There are often two workflows involved with pathology. While most reports come directly from hospital interfaces, there are often additional reports from ancillary systems or outside sources involving specialty testing. When these reports do not come directly from the hospital, a manual workflow may be required. You need to be sure the company has the capabilities to efficiently handle paper workflows when required. Radiology coding often has similar requirements.

     3. How do you flag problems or issues that arise?

When dealing with problems that arise, it’s essential for a company to have a dedicated system of checks and balances. A not infrequent example: a hospital changes its report format without advance notice. When these reports hit the interface, the information may not load. AdvantEdge has devised an entirely separate workflow to ensure that all files have been properly loaded, so the process moves forward without any glitches. This process scans reports before they are loaded to make sure the format is what was anticipated – or not. If changes were made to the format, they are flagged and stored in “error or exception” folders. The AdvantEdge IT department promptly contacts the hospital IT department or, if necessary, the healthcare provider to find out what was changed and why. It’s also essential to determine whether this was a one-time deviation or whether programming needs to be altered to accommodate permanent changes. 

How to Evaluate a Billing Company: Download Whitepaper Now! hbspt.cta.load(42247, ‘b73a66b1-d0a8-4e1e-92b3-9a7bc6ab1c86’, {“useNewLoader”:”true”,”region”:”na1″});

     4. Is your staff adept at handling implementations?  

Make sure a medical billing company has solid expertise in handling all types of implementations. One of the biggest challenges during implementation is securing all necessary data – and failure to do so is what accounts for most delays. If employees at a hospital or clinic are not adept at releasing data to third-party companies, the process can take considerably longer than anticipated. AdvantEdge has the expertise to get complex interfaces up and running within a 90-day window. Even in complicated situations, AdvantEdge has the experience to secure all necessary data for smooth implementations with the utmost accuracy, efficiency and speed. 

     5. Do you have proprietary software dedicated to optimizing medical coding and billing?

A company with proprietary software focusing on the specialized requirements of physician coding and billing brings considerable value to healthcare providers. For example, AdvantEdge’s proprietary software can integrate with almost any interface or type of file, making it easier to interface with hospitals that rely on proprietary or customized systems. During the implementation process, our specialized software can be programmed to run reports by revenue code, location of service, payor groups or by other requested information to accommodate the specific needs of hospitals and healthcare providers. This high level of customer service is available to our clients because we own the software code. 

This flexibility also enables AdvantEdge software to quickly adapt to changes in medical coding, billing, and compliance regulations.

Given the importance of technology and automated workflows, we have put together an upcoming “bonus” blog with additional questions to ask about the capabilities of a medical billing company. So, stay tuned. Until then, keep up to date on AdvantEdge and its medical billing initiatives by visiting our LinkedIn page.

Radiology reimbursement will be hit by two proposed changes in the 2022 Medicare Physician Fee Schedule:

These impacts are in addition to conversion factor and other proposed changes that will reduce 2022 radiology reimbursement. See 2022 Radiology Reimbursement: Good News and Bad News for those details. 

Regarding the wages for clinical labor staff:

“…these practice expense components are subject to budget neutrality, meaning increased spending in one place requires cuts elsewhere. As such, interventional radiology, radiation oncology and other specialties with high medical supply costs and lower spending on clinical labor positions could face significant reimbursement reductions next year, experts predict.”

To combat this, the Society of Interventional Radiology (SIR) is partnering with the American College of Radiology (ACR), the American Medical Association, and the CardioVascular Coalition to “pursue all regulatory and legislative options to protect radiology practices.” 

“CMS estimates cuts attributed to periodic labor pricing updates would land at 5% in interventional radiology and 1% for radiology. That’s in addition to a 9% cut for IR and 2% in radiology because of adjustments in the conversion factor used to calculate reimbursement, mandated sequestration and cuts to practice expense values. SIR said the proposed reductions represent a ‘perfect storm,’ resulting from the feds’ failure to keep labor rates current with inflation. 

For the 2022 MIPS program, CMS proposes to retire MIPS measure 195, covering stenosis measurement in carotid imaging reports and 225, related to reminder systems for screening mammography. In an Aug. 18 update, the American College of Radiology (ACR) said, “The pool of measures available to radiologists has been significantly reduced over the last few years of the MIPS program and the ACR intends to push back against the removal of additional radiology measures.”

Even worse, according to the ACR, is another proposal to remove quality bonus points for additional high-priority measures. And the CMS proposal to raise the data completeness threshold for quality measures up to 80% has been criticized. 



While mental health parity often takes a back seat in behavioral health billing, recent news shows that it has not been forgotten.

On August 12, Fierce Healthcare reported that UnitedHealthcare will pay $15.6 million to settle federal and state investigations into mental health parity. 

An investigation by the Department of Labor’s Employee Benefits Security Administration found that UnitedHealth would reduce reimbursement rates for out-of-network behavioral health services and would flag members who were undergoing mental health treatment for utilization reviews.

UnitedHealth Group, the parent company of UnitedHealthcare, said in a statement to Fierce Healthcare that the company is “pleased to resolve these issues related to business practices no longer used by the company.”

On a call with reporters, Acting Assistant Secretary for Employee Benefits Security Ali Khawar said that mental health parity enforcement is a key health priority at the Department of Labor under the Biden administration.

How to Evaluate a Billing Company: Download Whitepaper Now!

Despite these comments, in May Modern Healthcare reported that “Mental health services wane as insurers appear to skirt parity rules during pandemic.” 

Therapists and other behavioral healthcare providers cut hours, reduced staffs and turned away patients during the pandemic as more Americans experienced depression symptoms and drug overdoses, according to a new report from the Government Accountability Office.

In April, the American Psychological Association testified before Congress saying, “Stronger mental health parity law enforcement is needed to address the impact of the coronavirus.” APA Chief of Psychology in the Public Interest Brian Smedley, PhD told a House subcommittee ““The COVID-19 pandemic worsened what was already a mental health tsunami in this country. Research suggests we may be grappling with the mental health impact of this pandemic long after the pandemic itself ends. We must do more to improve access to mental health treatment for those who need it.”

He also went on to note a loophole in the parity law that is leaving many essential frontline workers without mental health insurance coverage and called on Congress to make several enhancements to existing legislation. 

With mental health parity in the news, will insurance company processes change? Or will we continue to see insurers “skirt parity rules” and reduce behavioral health billing and coverage?

Recent studies by MGMA show that many practices are paying EFT fees they did not agree to, raising medical billing and payment costs. Furthermore, this egregious practice has doubled during the past year! 

In an August 2021 survey, MGMA asked practice leaders, 

  • “Are insurers charging your practice fees you didn’t agree to when sending payments via EFT?” 
    • More than half (57%) responded “yes,” while 43% responded “no.”

A similar survey a year ago showed only 26% of groups paying fees to receive EFT reimbursement from payers.

MGMA believes this problem raises medical billing and payment costs and results from CMS action in 2017 that removed definitive guidance preventing health plans and payment vendors from charging these fees. 

MGMA’s position in a member Toolkit entitled Tips on Automating your Revenue Cycle and Avoiding EFT Fees is that health plan policies requiring network providers to contract with vendors who charge percentage-based fees to process the EFT/ERA transaction are inappropriate.

 “While it is within the right of any payment vendor to offer “value-added” services, these should be optional and the practice given the choice of receiving the EFT without any fees. Health plans or their contracted payment vendors should not require providers to incur such fees as the only method to receive EFT payments.”

How to Evaluate a Billing Company: Download Whitepaper Now!

MGMA is now pushing CMS to reinstate guidance that was in place in 2017 saying that only the provider’s financial institution may impose a fee to process EFT payments through the Automated Clearinghouse (ACH) Network. The guidance went on to specify that providers are not required to contract with payment vendors for “value-added services.”

  • Since payers frequently send payments through a designated payment vendor, providers often don’t have a choice. MGMA believes this has led to the explosion in EFT fees.

Recent studies and data throw cold water on expectations that patients will “catch up” on missed treatment and tests. With the current COVID resurgence, this trend is very likely to continue, impacting non-COVID hospital and physician reimbursement.

A study just published by Epic Health Research Network (EHRN) and KFF is titled, “Lack of an Admissions Recovery Suggests Some Are Forgoing Care Skipped Early in the COVID-19 Pandemic.” In a summary, KFF said, 

“Based on admissions data from 250 hospitals across 47 states, the analysis estimates hospital admissions during the first three months of 2021 were 89.4% of what would be expected in the absence of the pandemic. The pattern continued through the week of April 3, when admissions were 85.5% of expected levels.”

The study goes on to say, “If we remove patients with a COVID-19 diagnosis, we see that all other admissions are 80.7% of expected levels based on pre-pandemic usage in the week of April 3, 2021.”

Healthcare spending shows the same trends. Official US Bureau of Economic Analysis figures show that overall healthcare spending has returned to pre-pandemic levels but is 7.1% below expected levels in June, 2021 (the latest available data).

Similar COVID impacts are reported by Radiology Business in new research that showed 

“For every positive COVID-19 test during one recent period, radiologists recorded about 1.2 fewer outpatient imaging exams one week later.”

With COVID hospitalizations and cases continuing to rise, all of these data suggest that physicians and hospitals should expect non-COVID volumes and reimbursement to be weak, well below pre-pandemic expectations. 

How to Evaluate a Billing Company: Download Whitepaper Now!




Determining Patient Propensity to Pay

In a previous post, we discussed how AdvantEdge works with patients to help them meet their financial obligations with empathy and individualized payments. Now learn how we use technology to increase the number of resolved claims so that healthcare providers receive their payments as quickly and efficiently as possible. Read more

Healthcare Roundup

Radiology | 2 min read

Radiology Reimbursement: Good News and Bad News

There is good news and bad news for radiology in proposed changes for 2022 reimbursement.. Read More

HHS | 2 min read

5 Things to Know About the No Surprises Rule

The Interim Final Rule on July 1 severely limits balance billing. Check out 5 things you should know when the rule goes into effect on January 1, 2022. Read More

ASC | 2 min read

4 Bold Predictions for the ASC Industry

Six ASC leaders offer predictions for industry trends that cover industry growth, obstacles for independent ASCs, hospital partnerships, and insurance partnerships.  Read More

COVID-19 | 1 min read

COVID’s Resurgence in 2 States Interrupts Elective Surgeries

While healthcare price increases have recently dropped to 2% (from 2.5%+ over the past year), a PwC report suggests that healthcare costs will increase by 6.5% in 2022 due to continued COVID-19 impacts on spending. Read More


Is the Labor Shortage Hurting Your Billing Today? Tomorrow?

Is your practice having trouble hiring billers? Read our report on why a medical billing service might be right for you.


Practice Review Kit




Can determining “patient propensity to pay” improve collections and patient satisfaction? Yes!

In a recent blog post, “Treating Your Patients with Care,” we outlined how a larger and larger portion of  healthcare financial responsibility is being placed on patients; and the ways in which AdvantEdge Healthcare compassionately and empathetically connects with individuals to help them meet their financial obligations. With that in mind, we want to address how AdvantEdge is leveraging proprietary technology to increase the number of resolved claims, so healthcare providers receive full payment as quickly and efficiently as possible. 

Empowered by Technology & Outstanding Service

Leading-edge technology coupled with a forward-looking approach about the ways in which we can positively impact our customers is a fundamental principle at AdvantEdge. This is just one of many reasons why we remain a leading national medical billing company offering optimal service throughout the entire revenue cycle management process. Our skilled team is constantly upgrading and fine-tuning our Virtual Manager platform to incorporate new technology(ies) where one of our most important goals is to assist patients through the claims resolution process, so that clients get paid fast – and in full. For example, AdvantEdge is currently testing new services through text messaging and e-wallets that allow patients to receive billing statements directly to, and make payments from, their digital wallets to facilitate the resolution process. 

Services that Literally Pay Off – the AdvantEdge Patient Propensity to Pay Scale:

AdvantEdge also leverages propensity-to-pay tools that provide valuable and relevant information to ensure they are availing patients to the right tools and resources to satisfy their payment obligations. Using this data, AdvantEdge can also apply the right tactics and prioritization based on their understanding of the patient’s ability and desire to meet financial obligations. A patient’s ability and desire to make payments tends to fall into one of four categories on the AdvantEdge Patient Propensity to Pay Scale: 

AHS-Pay-ScaleClick on image to view larger graphic.


Realizing Optimal Outcomes

Using policies, tactics, and workflows that meet patients where they are (and where they potentially can be) enables effective collections for clients while treating patients with the compassion and empathy they deserve. As recent studies have illustrated, 18% of American’s are in the process of paying off medical debt. Adding to that debt doesn’t help AdvantEdge clients or their patients. Sophisticated technology, empathetic staff, and smart approaches tailored for each patient are designed to optimize outcomes for clients and patients alike. 

Do you want your healthcare practice to realize optimal outcomes from your accounts receivable efforts? AdvantEdge invites you to learn more about how our clients benefit from the AdvantEdge promise: More Money, Faster; Client First Service; Compliance and Privacy; and Information Anytime, Anywhere.  Visit the AdvantEdge website and stay up to date on AdvantEdge and medical billing news on our LinkedIn page.

There is good news and bad news for radiology in proposed changes for 2022 reimbursement.

Good news

Bad news

  • The proposed Medicare Physician Fee Schedule (MPFS) for 2022 estimates a CY 2022 conversion factor of $33.5848 compared to 2021 at $34.8931.
  • CMS estimates an overall impact on radiology to be a 2 percent decrease, with interventional radiology seeing a decrease of 9 percent, nuclear medicine a 2 percent decrease and radiation oncology and radiation therapy centers a 5 percent decrease.
  • The American College of Radiology, the AMA and others are lobbying Congress to offset the 2022 decreases.
  • If the pause in the two-percent sequestration cut is allowed to expire, as planned, on December 31, 2021, these decreases will be larger, unless Congress intervenes.
  • Late in 2021, Congress included a 3.75 percent adjustment to the 2021 conversion factor which rolled back the payment cuts to radiologists from 10 percent to approximately 4 percent. While Congressional action is possible for 2022, that uncertainty will remain until late this year.


On July 1, HHS and other federal departments issued a 411-page Interim Final Rule (IFR) to implement the No Surprises Act passed by Congress in late 2021. These provisions go into effect January 1, 2022. We highlight 5 things to know about the No Surprises Act:

  1. Billing at of out-of-network (OON) rates will be much more difficult
  • Most/all emergency situations, including most follow-up care must be paid at in-network rates
    • This includes most hospital-based providers, not just ER physicians
  • Non-emergency care will require substantial advance notice, including a good faith estimate of costs provided to the patient
  1. Emergency treatment at hospital ERs and free-standing ERs will essentially be paid at in-network rates

Specifically, the IFR requires emergency services to be covered

  • Without prior authorization.
  • Regardless of whether the provider is an in-network provider or an in-network emergency facility.
  • Without limiting what constitutes an emergency medical condition solely on the basis of diagnosis codes.

Initial emergency care, post stabilization and potentially follow-up in-patient treatment are included in the definition of “emergency.”

  1. Emergency treatment includes “ancillary services”; i.e. most hospital-based providers

In addition to emergency medicine, anesthesia, radiology, pathology, hospitalist, neonatology and other “ancillary services” are included in the provisions.

  1. While the payment rules are complex, patients must pay no more than their in-network deductible and cost share

The “No Surprises Act” limits what patients pay in these scenarios to their in-network cost-sharing amount. It also applies this cost-sharing to their in-network deductible and annual out-of-pocket maximum, prohibits the patient from being balance billed for any additional amount, and removes the patient from the reimbursement dispute process between their health plan and the OON Provider.

The patient’s cost-sharing is not based on the total OON charge. Rather, it is based on a “qualifying payment amount (QPA).” The IFR defines the “qualifying payment amount” as the lesser of the billed charge or the health plan’s median contracted rate unless otherwise specified by a state’s law or by an All-Payer Model Agreement. 

The IFR details how health plans must calculate the median rate for the QPA. The agencies will conduct regular audits of health plans to ensure compliance with how the QPA was calculated.

Payment must meet these criteria

  • An amount determined by an applicable All-Payer Model Agreement under section 1115A of the Social Security Act.
  • If there is no such applicable All-Payer Model Agreement, an amount determined under a specified state law.
  • If there is no such applicable All-Payer Model Agreement or specified state law, an amount agreed upon by the plan or issuer and the provider or facility.
  • If none of the three conditions above apply, an amount determined by an independent dispute resolution (IDR) entity.

The IFR leaves the IDR to be defined later. 

  1. For non-emergency situations, prepare for notices and consents

If you practice in an in-network hospital but are not in-network with a patient’s insurance, you must provide an electronic or paper notice. The notice is intended to prevent surprise bills when the patient incorrectly assumes the services will be in-network. The notice is to include charge estimates and alternative in-network providers available (if any) and a clear statement that consenting to out of network services is optional and that in-network providers may be available.

Notice and consent can only be sought for certain non-emergency services or certain post-stabilization services. 

To balance bill for post-stabilization services, an OON provider or emergency facility must provide notice and get consent from the (stabilized) patient but only if these four conditions are met.

  1. The treating provider must determine that the patient is able to travel using nonmedical transportation to an in-network provider or facility within a reasonable travel distance, taking into consideration the individual’s medical condition;
  2. The provider/facility must satisfy notice and consent criteria (a model notice was published simultaneously with the IFR);
  3. The participant or their authorized representative must be in a condition to provide informed, voluntary consent; and
  4. The provider/facility must satisfy any additional state law requirements.


Why AI Technologies are a Fit for Medical Billing Companies

WARREN, NJ – July 27, 2021: AdvantEdge Healthcare Solutions (“AdvantEdge”), a leading national medical billing company with comprehensive, coding, practice management and revenue cycle management services, today released a Special Report about how Artificial Intelligence (AI) and Machine Learning (ML) are transforming the medical billing landscape.

Three highlights from the report offer an inside view about how AI and ML are impacting medical billing and how these technologies allow healthcare providers to ensure all billing – and the entire revenue cycle management process –  is handled efficiently, accurately, and in a timely manner.

  1. AI is A-OK: The tremendous amounts of information captured every day from hospital information systems, clinical platforms, and patient accounting systems leaves a large margin for error. Inconsistencies and incorrect information can be efficiently and expediently addressed by automating certain processes using artificial intelligence. 
  1. A Matter of Time: Patients should be able to interact with chatbots around the clock to resolve a variety of issues, allowing customer service representatives to handle more complex issues that cannot be more simply resolved.
  1. Meet Machine Learning: A subset of AI, ML possesses the ability to automatically learn and build on prior knowledge – without explicit programming. ML can handle a wide range of billing discrepancies and payer behaviors that would be nearly impossible to address otherwise. 

Click here to read this Special Report in its entirety. 

About AdvantEdge Healthcare Solutions
AdvantEdge is recognized as one of the top ten U.S. medical billing companies providing billing, certified coding and practice management services to healthcare providers nationwide. AdvantEdge collects more than $1 billion annually for physicians, hospitals, ambulatory surgery centers, behavioral health agencies and large office-based medical groups. Client-first service, robust technology, and actionable business intelligence and reporting translate into healthier practices and enable AdvantEdge’s clients to have the freedom to focus on delivering world class clinical care to their patients. To learn more about AdvantEdge, visit our website at Follow us on Twitter at @DoctorBilling and on LinkedIn.


Last Thursday, the Biden administration unveiled the Interim Final Rule, indicating how the No Surprises Act will be implemented. While comments are being solicited until September 1, HHS chose to skip a Proposed Rule and go straight to an Interim Final Rule, most provisions of which will be effective January 1, 2022. 

Congress approved the No Surprises Act last December in order to eliminate so-called “surprise billing.” The Rule requires billing in emergency situations to match in-network rates with no requirement for prior authorization. The rule also prohibits out-of-network charges for ancillary services, such as radiology, anesthesia, and other providers, at an in-network facility. 

Restrictions on out-of-network charges also apply to non-emergency situations, such as childbirth. How these provisions will apply to specialists is of particular interest and concern, and may lead to tension between providers and patients, according to Axios.  In most, if not all, cases, providers will be required to post notices related to possible out-of-network billing.

Not addressed in the rule was an arbitration process, required by legislation, for cases where in-network rates are not established. Ground ambulance billing is also not addressed because it was excluded from last year’s legislation. 

To learn more, please find additional coverage on the Interim Final Rule:

Radiology Business: Surprise Medical Billing Ban One Step Closer as Biden Administration Unveils Final Rule

Modern Healthcare: CMS Bans Surprise Billing

Fierce Healthcare: Biden Admin Releases First Rule Banning Surprise Medical Bills




Is the Labor Shortage Hurting Your Billing Today? Tomorrow?

Is your practice having trouble hiring due to the labor shortage? Is this already impacting your billing needs, or will it in the near future? Medical practices have two billing options: partnering with a medical billing company or supporting an in-house billing department—where costs are increasing every day. The right option for you depends on both effectiveness (measured by performance) and efficiency (measured by costs). Check out our most recent blog post for more. Read more

Healthcare Roundup

COVID-19 | 1 min read

New OSHA COVID-19 Rules for ALL Healthcare

New U.S. Labor Department COVID-19 workplace safety rules go into effect July 6. Among other requirements, they mandate that employers provide PPE, paid time off to get vaccinated and to recover from side effects and more. Read More

CMS | 2 min read

Pandemic Swells Medicaid and ACA Enrollment, a ‘High-Water Mark’

According to a recent report, Medicaid enrollment grew from 71M in February 2020 to over 80M in January 2021. In addition, ACA marketplace plans have added a million enrollees since February, now covering over 12M. Read More

Telehealth | 1 min read

Americans Want Telehealth to Stay

U.S. health industry leaders and patient advocates, notably HHS Secretary Xavier Becerra, are pushing Congress and the Biden administration to preserve the pandemic-fueled expansion of telehealth services. Read More

CMS | 1 min read

Healthcare Price Increases Slow, but Projected to Rise Next Year

While healthcare price increases have recently dropped to 2% (from 2.5%+ over the past year), a PwC report suggests that healthcare costs will increase by 6.5% in 2022 due to continued COVID-19 impacts on spending. Read More

AdvantEdge News | 1 min read

AdvantEdge Wins Bid to Provide EMS Billing Services to Carroll County, MD

Read more about our new client, Carroll County, MD, and how AdvantEdge will provide a full suite of services to standardize billing for their Fire/EMS department. Read More

In-house Medical Billing vs. Outsourced Revenue Cycle Management

Learn about the key factors in supporting an in-house medical billing department or using a medical billing company.


Practice Review Kit




In the Midst of a Labor Shortage, Is Your In-house Billing Operation Still Performing?

Is your practice or department having trouble hiring billers? Have you lost staff during the COVID pandemic? If so, you aren’t alone. Many workers haven’t returned for a variety of reasons, from not having child care to generous unemployment packages to fear of getting sick, per a recent article in The New York Times. And, surprisingly to many, the labor shortage is expected to be long term, not just a short-term inconvenience!

Medical practices have two billing options: partner with a professional medical billing company or support an in-house billing department. The right option for you depends on both efficiency (measured by cost) and effectiveness (measured by performance). 

Efficiency (cost)

Consider a practice with a four-person billing staff where one needs to be replaced due to COVID or other reasons. From a cost perspective, the four staff members typically would get two to three weeks of vacation and five to 10 sick/personal days. That means 60 to 100 days out of the year, 25 to 40 percent of workdays, where the department is operating short-staffed. A larger staff has the same issue, with slightly less impact on productivity. But in all cases, the costs for salaries, benefits, and other overheads go up every year. And, considering the labor shortage, expect them to go up faster, to higher levels than most are forecasting. 

There are also overhead costs associated with in house billing. Hiring, training and supervision are obvious ones, but don’t forget benefits, bonuses, billing system, IT support, training, office space, miscellaneous costs, etc. Given the current and expected labor shortage, it’s important to factor in significant annual cost increases in nearly all of these areas. Once you assess all these personnel and overhead costs, you can compare them with a medical billing company fee. Note that most, if not all of these costs are increasing every year.

While not strictly a cost issue, some physicians find managing a billing staff takes more time and effort than they would like: especially when staff shortages or other daily challenges interfere with revenue generating clinical activities, or family time. For many practices, the current labor environment is exacerbating this concern and causing tremendous burdens on the physician(s) responsible for overseeing the billing operation’s performance. 

Medical billing services typically charge a percentage of the collected reimbursements. This is a variable expense vs. the fixed cost of in-house billing. Also, these fees are usually locked-in for a three or five year period. In other words, while the costs of running an in-house operation are generally fixed and increase every year, the costs of using a billing company are variable, based on performance and can be locked in for three to five years, sheltering your practice from escalating labor and other costs. 

Is it less expensive to bill in-house? Usually not, given the economies of scale of a sophisticated billing company. But each practice needs to do the math for its unique situation. Just be sure, given the current and expected labor environment, to factor in significant annual cost increases for in-house billing.


Many in-house billing operations are effective at collecting reimbursements owed. But this effectiveness is at risk without a stable, trained staff and consistent management and leadership. Where specialized skills are required, the challenge can be even greater. As the patient portion of reimbursement grows, it takes a very specialized staff to share patient compassion and, at the same time, be effective in a collection effort.  This can be extremely difficult to train and manage in-house.

If you partner with a medical billing company, many of the challenges that affect a small or medium-size team are eliminated. A medical billing company should bring state of the art billing software as well as professionals with expertise in your specialty plus medical coding and billing that are up-to-date on regulations, compliance, and other industry standards. 

If a practice requires specialized skills (e.g. specialty coding), a medical billing company may be much more effective (and efficient). If a practice requires the equivalent of specialized skill half of the month, they may need a full-time person on staff. Medical billing companies can share specialized resources across clients. They are also likely to have better training opportunities and better career paths for coders and billers than with most in-house billing operations, leading to greater stability and experience.

At the end of the day, a physician practice generally tries to minimize the expenses of its in-house operation, since it is a “cost center.” This means investing as little as possible in tools, training, technology and people. In contrast for a billing company, like AdvantEdge, the billing operation is its revenue center and enjoys meaningful investment in tools, training, technology and people.  If interested, a great way to measure your performance against that of a medical billing company is to compare your current net collections percentage, days in A/R, and A/R greater than 120 days outstanding (the three most identifiable metrics used by the industry) to projections from a medical billing company. 

As the news points out, now is a good time to assess or re-assess your staffing situation and business methodologies…as Bob Dylan said, “The times they are a’ changing.” You need to make sure you are staying current and, potentially, changing with them. To see if a medical billing service might make sense for your practice, reach out to an AdvantEdge expert today to learn more. You can also follow AdvantEdge on LinkedIn to stay current on company and medical billing industry news.


We’re proud to announce that AdvantEdge has been selected to standardize EMS billing for the Carroll County Fire/EMS Department, which is a new Department of the Carroll County Government, created in October of 2020. The Department consists of 14 fire stations, providing Basic Life Support (BLS) and Advanced Life Support (ALS) services from 15 ambulances. AdvantEdge scored the highest of nine potential medical billing companies by a Carroll County committee formed to evaluate the technical and financial capabilities of each vendor. 

AdvantEdge will provide a full suite of emergency medical transport billing, collection, and financial reporting services. 

“AdvantEdge has a lot of experience working with counties and local communities, and is one of the leading companies that provide billing services for ambulance and EMS in the state of Maryland,” stated David Langsam, President and CEO of AdvantEdge. “We look forward to working with Carroll County and unifying their billing services with our proprietary technology and client-first approach.”

To learn more, please read coverage on EMS1.  

Learn more about how we can help you with your medical billing needs by visiting, and stay up-to-date on AdvantEdge news and trends by visiting our LinkedIn page. 

As one of the most critical components of the medical billing process, medical coding cannot be overlooked when it comes to ensuring that healthcare providers collect all money due for services delivered. In this blog post, we suggest Key Questions about medical coding. A medical billing company must have stellar coding capabilities to achieve successful financial outcomes for its clients. Unfortunately, many providers fail to investigate medical coding capabilities prior to partnering with a medical billing company. Here are eight key medical coding questions to ask of your billing department, current medical billing company or billing company you are considering. What you don’t ask about coding can hurt your bottom line!

1. Are your coders certified and do they have the specific certifications associated with my specialty(ies)?  It’s impossible to offer superior coding capabilities without employing the best people for the job. Coders should not only have the necessary credentials, but the credentials specific to your area(s) of practice, as well as extensive and relevant expertise, and depth of knowledge required to handle the complexities of the coding process. As an example, AdvantEdge coders have deep credentials in each of our clients’ specialties, including radiology, interventional radiology, emergency medicine, pathology, pain management, and anesthesia, among others, along with certifications and experience in subspecialties (neurological radiology, derma pathology, etc). To help clients keep up with the most current industry updates and changes, ongoing in-house training is required of all coders, including annual ICD-10 and CPT updates. 

2. How quickly can you adapt to planned or sudden and unpredictable changes on the medical coding frontier? Recent history has taught us that change is inevitable and unpredictable. This was witnessed with COVID. A medical billing company must adapt to change efficiently and expediently – whether the change is planned or takes the industry by surprise. AdvantEdge was able to adapt to COVID largely because of the company’s technology foundation and the expertise of its people who were well equipped to work remotely. Due to proprietary technology and extensive protocols that were already in place, the AdvantEdge coding team responded to the new COVID landscape with relative ease. The rapid emergence of telehealth and COVID coding rules were quickly adapted with new training and updated workflows. What’s more, AdvantEdge is also prepared with transition strategies when COVID coding provisions potentially revert to pre-COVID status. As another example, when providers were given the direction earlier this year to select E/M codes based on total time spent or medical decision making (MDM), AdvantEdge was well prepared and quickly incorporated this change.

3. What is your process when dealing with coding related denials? Although denied claims are an inevitable reality, the issue is how – and if – these denials could have been avoided and are dealt with in a way that allows for the best possible financial outcomes. Coding denials should be tracked and trended to identify systemic areas of concern, either related to provider documentation, information flow from provider location(s), or issues related to coding performance within your coding department (or that of the billing company you use).  Quantification and trending of these denials are the best ways to ensure you are identifying and addressing root causes to ensure problems are being resolved and do not perpetuate.  AdvantEdge has a cohesive and time-tested process for handling denied claims to ensure they are addressed and handled expediently. When it comes to claim denials, fast and thorough follow-through is essential to making sure each valid claim is reimbursed for our clients.  Additionally, AdvantEdge provides its clients with detailed denial reports that demonstrate how denials trend over time, to ensure positive progress and momentum, leading to improved and expedited cash realization for clients.

4. How often do you audit your practice’s (or in the case of a billing company, how often do they audit their client’s) documentation for compliance purposes?  A practice doing its own billing, or its medical billing company, must ensure that they, as well as the physicians they serve, are aware of the relationship between documentation and coding in order to remain compliant. This necessitates ongoing oversight and audit of documentation. For this reason, AdvantEdge provides most clients with a formal audit at least annually, offering valuable feedback to help providers understand any issues that may arise and need to be addressed.  As necessary and /or as desired by clients, AdvantEdge also provides them with education on proper coding and documentation. If AdvantEdge notices trends of coding errors or other inconsistencies, root cause analysis is completed followed by an action plan that incorporates preventative measures for moving forward, independent of the audits mentioned above.

5. What is your typical coding turnaround time (TAT)? We all know that time is money. At AdvantEdge, the majority of our clients have a 48-hour coding turnaround time. If there is a unique situation around specific claims, our team is always equipped with an action plan to handle those exceptions. When it comes to medical billing and coding, we understand that time is of the utmost importance.

6. What actions are taken if a payment comes in lower than the current fee schedule allows due to coding discrepancies? Your billers or medical billing company must be aware of the most current contracts and fee schedules to ensure that you get the proper amount due for delivery of services. Your billing department or billing company needs to have a system in place to track payments against contractual amounts, otherwise these underpayments will not be flagged and may get inappropriately transferred to patients or written off as bad debt.  While these “underpayments” may seem arbitrary, oftentimes they are coding related, and you need to ensure you have appropriate documentation to evidence the procedures performed, along with related acuity levels, to overturn such underpayments.  AdvantEdge understands that many providers don’t have time to investigate annual contract and fee-schedule updates, so we keep abreast of these changes and have the systems necessary to load clients’ payer contracts into our system.  This process enables us to identify underpayments as exceptions and follow up with payers to appeal and overturn such underpayments before seeking to collect from the patient or another third party…all to ensure we are collecting all money due to our clients.

7. In the case of a billing company, do clients have access via phone to live coding specialists to answer questions about complex medical coding issues that may arise?  Although technology is integral to the medical coding process, some situations require human intervention. A medical billing company must have coding experts on hand to deal with unique and complex situations that require human intervention and interaction. AdvantEdge realizes the importance of giving our valued clients access to appropriate specialists who can promptly explain, address, and resolve questions that require immediate clarification.

8. Does the company utilize leading edge technology and automated workflows to assure full reimbursement? One of the keys to properly billing for your practice or becoming a leader in medical billing is a company’s ability to incorporate and utilize the latest technologies. AdvantEdge’s proprietary software allows us to quickly adapt to changes in coding regulations, along with all aspects of revenue cycle management [from beginning to end].  This enables us to deploy more human resources where they can have the biggest impact, such as managing exceptions, educating our clients, communicating with your patients, and handling complex claims and other items that may arise in the billing process.

The second blog in our three-part medical coding series will highlight the importance of technology and automated workflows. Until then, keep up to date on AdvantEdge and its medical billing initiatives by visiting our LinkedIn page.