Choosing the Right Physician Billing Software: A Guide for Healthcare Providers

Healthcare providers are under a lot of pressure to improve revenue cycle management (RCM). But that’s tough to do without effective medical billing software to tackle traditional workflow challenges that clog critical processes — like managing claims denials. The threat of claims denials can lead to delayed payments, higher recovery costs, and unhappy patients.

Top takeaways:

• Effective medical billing software is essential for managing rising claims denials, reducing revenue leakage, and improving overall revenue cycle performance.
• Automation within physician billing software helps eliminate manual errors, speed up payments, and reduce labor costs by streamlining eligibility checks, claim scrubbing, and appeals workflows.
• Advanced rules engines in medical billing software improve clean claims by validating against current CMS and commercial payer rules before submission.
• Robust analytics and reporting in physician billing software give leaders visibility into denial trends, days in A/R, and cash flow, enabling data-driven RCM improvements.

In our recent survey, executives across care settings cited claims denials as a significant challenge. That’s true for:

• 90% of RCM managers and leaders at mid-large hospitals
• 74% of specialty physician practices
• 83% of home health practices

And when claims are denied, revenue leakage often follows. Even though some hospitals have more than 20 staff members dedicated to dealing with denials, half of hospitals and health systems recover less than 50% of denied claims charges, resulting in a painful hit to the bottom line. In fact, larger hospitals estimate denial-related losses can be as high as a whopping $10 million annually.

Physician and specialty practices are also leaving money on the table. Only two in five ambulatory practices recover 75% or more of denied claims charges; but a nearly equal number recover less than half.¹

In addition to claims denials, errors in medical billing and coding could mean audits and legal penalties — plus potential noncompliance with fraud and abuse laws. And if that happens, an organization could find itself excluded from government programs like Medicare and Medicaid.

But there’s good news. Through the power of automation, the right medical billing software can help speed up payments, reduce costs, ensure compliance, and improve the patient experience.

How physician billing software works

For most providers, manual processes are the leading contributor to labor overages and RCM errors that cost time, money, and result in patient dissatisfaction.

Effective physician billing software keeps revenue flowing by using automation to speed up reimbursements with eligibility checks, claims status tracking, audits and appeals, and remittance management for government and commercial claims – all in a single system. Additionally, electronic health record integration enables clean workflows between billing and patient records to improve both efficiency and patient care.

But not all physician billing software is created equal. If you’re on the hunt for the right solution, be sure your candidates offer:

• HIPAA compliance to ensure adherence to privacy regulations
• Support for both front-end and back-end RCM processes
• Comprehensive analytics and reporting capabilities
• Open communication and support channels
• Workflows designed to meet your needs

Benefits of using physician billing software

Inovalon’s Claims Management Pro physician billing software offers many benefits — including faster reimbursement and improved cash flow, a reduction in billing errors, fewer claims denials, and enhanced compliance and efficiency. With it, you can:

Improve clean claims. Leverage an advanced rules engine that immediately scrubs claims against the most up-to-date CMS and commercial payer rules, allowing you to correct errors before claims go out the door.

Simplify eligibility checks. Verify eligibility across all payers during claim upload and see flagged errors so claims can be edited before submission.

Streamline claims resolution. Decrease days in A/R with automated workflows for audit responses, appeal submissions, and ADR tracking.

Maximize staff efficiencies. Customize staff workflow assignments based on the type of claim and action needed.

Prevent write-offs. Automate secondary claims submissions to stop timely filing write-offs.

Enhance audits and appeals. Increase claims revenue with automated workflows for faster, more successful audits and appeals.

Speed up posting. Access and download ERAs with one login for accelerated payment posting.

Physician billing software success stories

By using the right physician billing software, providers across the healthcare ecosystem can overcome even the most daunting RCM challenges. Check out the following success stories to learn how Inovalon’s RCM solutions helped them do it.

End-to-end RCM efficiency: How Paramount Healthcare transformed their billing processes

Care setting: Skilled Nursing and Rehabilitation Facilities

Success: “Payments are like night and day. We don’t have to spend time keying in payments; we’re fully integrated (with PointClickCare) and once payments actually hit the bank, it flows in overnight to PointClickCare.”

Managing patient coverage and billing needs is complicated for many skilled nursing facilities. For Paramount Healthcare, keeping up with the billing demands of their 12 facilities was becoming overwhelming and inefficient. Between confirming active coverage, reverifying Medicare coverage, creating and tracking claims, and posting payments – and doing all these steps in different systems – the billing team had a mountain of challenges affecting their revenue cycle.

Fortunately, an end-to-end approach to RCM transformed Paramount Healthcare’s billing success. With Inovalon’s integrated software, the billing team can now complete eligibility inquiries, stay on top of coverage changes, manage their claims from start to finish, and more.

Read the Paramount Healthcare success story.

PAM Health’s Inovalon experience: Exceptional service, clean claims, and maintained connections

Care settings: Long-term acute care, physical medicine and rehabilitation, and behavioral health

Success: “Our pending claims were at $5M one day and down to $2.5M the next day due to Inovalon’s rerouting efforts.”

PAM Health serves medically complex and rehabilitation patients across a network of over 100 long-term acute care hospitals and physical medicine and rehabilitation hospitals, along with wound clinics, outpatient physical therapy sites, and behavioral health hospitals spanning 17 states.

The organization is committed to providing high quality patient care and outstanding customer service for all patients it serves.

To maintain a healthy revenue cycle and improve revenue performance, PAM Health leverages Inovalon’s RCM software. Our solutions have helped increase collections, decrease days in A/R, and achieve a higher clean claims rate.

Read the PAM Health success story.

Frequently asked questions on choosing the right physician billing software

Why is medical billing software so important for revenue cycle management?

Effective medical billing software is critical because it automates many of the manual tasks that cause delays, errors, and lost revenue. By streamlining eligibility checks, claim scrubbing, status tracking, and remittance posting, it helps reduce claims denials, speed up reimbursements, and minimize revenue leakage across the entire revenue cycle.

What key features should I look for in physician billing software?

When evaluating physician billing software, prioritize:

• HIPAA compliance and strong data security
• Support for both front-end and back-end RCM
• Integration with your EHR to enable clean clinical-to-billing workflows
• Advanced analytics and reporting to track denials, days in A/R, and collections
• Configurable workflows so the system adapts to your practice or organization, not the other way around

How does medical billing software help reduce claims denials?

Modern medical billing software uses powerful automation and rules engines to scrub claims against up-to-date CMS and commercial payer rules before submission. It flags coding issues, missing data, and eligibility problems early, so staff can correct errors in advance. This leads to higher clean-claim rates, fewer denials, and less time spent on rework, audits, and appeals.

The RCM imperative

Claims denials are on the rise. To remain profitable, it’s imperative that healthcare providers improve revenue cycle efficiency. Applying the power of automation to RCM can help maximize efficiency, reduce labor costs, speed up payments, and improve the patient experience.

That’s why organizations like Paramount Healthcare and PAM Health rely on physician billing software like Inovalon’s Claims Management Pro.

But don’t just read about how providers like these have enhanced their operations. Schedule a demo to see for yourself the benefits of this powerful solution.

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