Every medical practice wants to get paid faster, have fewer denials, spend less time chasing claims, and have a healthy AR. These are goals that just about every biller, practice manager, and physician shares. But knowing what you want and knowing how to build a billing workflow that actually gets you there are two very different things.
What separates a high-performing billing operation from an average one isn’t talent. It’s process. It’s having a clear, disciplined sequence of steps that happens consistently. It should happen before the patient is seen, while the claim is being built, after it’s submitted, and throughout the follow-up cycle. When each stage of that workflow is functioning well and connected to the next, the whole revenue cycle moves faster and more cleanly.
Here’s what that billing workflow actually looks like from start to finish.
Stage 1: Before the Patient Is Seen
The billing cycle doesn’t start when the provider walks into the exam room. It starts days before the appointment and the practices that understand this have a significant advantage.
Run Batch Eligibility 72 Hours Out
Don’t wait until the patient is standing at the front desk to confirm their coverage. Running a batch eligibility check through Medisoft EDI (also known as eMEDIX) 72 hours before the appointment gives your team time to identify coverage issues, locate replacement plans, and contact patients if needed before the day of the visit. If you don’t have eMEDIX yet, you can learn more about how Medisoft EDI can streamline your billing process here.
Use the Cost Estimator
High-performing billing teams use tools like Medisoft EDI’s PRE (Patient Responsibility Estimator) to calculate what the patient will owe based on their CPT codes, deductible status, copay, and coinsurance. Giving patients a printed estimate before or at the time of their appointment dramatically improves same-day collections because it’s always easier to collect at time of service than to chase a balance through statements later.
Confirm Authorization
If the service requires prior authorization, it needs to be secured and documented in the system before the visit, not after. A claim denied for missing authorization is entirely preventable and fixing it is time-consuming.
Stage 2: Charge Entry and Claim Submission
Once the patient has been seen, the clock starts. High-performing billing operations don’t let charges sit.
Capture Charges Within 24 Hours
The standard in top billing teams is same-day or next-day charge entry. Every day that passes between the visit and charge entry is a day that details get harder to confirm and revenue gets delayed. Providers should be documenting and signing off on encounters within 24 hours so claims can be built and reviewed promptly.
Verify Coding Accuracy
Before a claim goes out, someone should be checking that CPT codes and ICD-10 diagnosis codes are matched correctly, that modifiers are applied where needed, and that diagnosis codes are as specific as possible. Unspecified codes are one of the most common and easily preventable denial triggers. This is not about second-guessing the provider. It’s about supporting accurate billing so that legitimate charges get paid.
Run Claims Through a Scrubber Before Submission
Medisoft EDI includes a claim scrubbing engine with more than 500 configurable edits that catch problems before they ever reach the payer. NCCI edit conflicts, invalid CPT codes, eligibility issues, place of service mismatches the scrubber flags these automatically. The goal is to have 95% or more of claims make it out to the payer without requiring any manual intervention.
Submit Within 2 to 3 Days of the Visit
After charges are entered and claims have been scrubbed, they should be transmitted to the clearinghouse and on their way to the payer within 2 to 3 days of the date of service. That timeline accounts for a biller’s review and any front-end corrections. All the while still keeping the submission window tight enough to support healthy cash flow.
Stage 3: Remittance and Payment Posting
Once claims are out the door, the next milestone is getting paid and posting those payments accurately and quickly.
Target ERA Payment Within 14 to 21 Days
For most payers and claim types, a clean claim submitted electronically should generate an ERA response within two to three weeks. If you’re not seeing ERAs within that window, it’s a signal worth investigating. Either something was missed on the front end or there’s a payer-side issue to address.
Post Payments the Same Day ERAs Arrive
This is non-negotiable in high-performing operations. Every day a remittance sits unposted is a day your AR looks worse than it actually is. And is a day you can’t act on any denials that came back with that remittance. With automated ERA posting through Medisoft EDI, payments, adjustments, and denials are applied to accounts in real time without manual data entry.
Get Patient Statements Out Quickly
When ERA posting is automated and balances transfer in real time, patient statements can go out almost immediately after the insurance payment is processed. Faster statements mean faster patient payments and fewer accounts that drift toward collections.
Stage 4: Denial Management and Ongoing AR Follow-Up
No billing workflow is complete without a disciplined approach to what happens when claims don’t get paid the first time.
Follow Up on Unpaid Claims at 30 to 45 Days
If a claim hasn’t generated an ERA, whether a payment or a denial, within 30 to 45 days of submission, don’t wait for the payer to reach out. Have your team check the web portal or make a phone call to find out why. Payers won’t always proactively notify you when something was missed. And if a claim was somehow lost or misdirected, timely filing deadlines are still counting down.
Work the Aging Report Aggressively
Running a regular aging report and prioritizing anything approaching the 90-day mark is standard practice for high-performing billing teams. Especially with payers like Humana that have 90-day timely filing limits. Once a claim passes that threshold, your options become very limited.
Use Denial Data to Find and Fix Root Causes
Medisoft EDI provides detailed denial management reporting that lets you drill down by payer, denial code, and denial reason. This matters because individual denied claims are symptoms. The root cause often might be a coding pattern, a front-desk process, or a payer rule change. When you can see denial trends clearly, you can fix the underlying issue and prevent the same denial from recurring across dozens of future claims.
The Benchmarks That Tell You How You’re Doing
How do you know if your workflow is actually performing at a high level? These are the key metrics worth tracking consistently:
- First pass (clean claim) rate: 95% or higher
- Denial rate: 5% or less
- Days in AR: 35 days or less
- 90+ day AR percentage: 15% of total outstanding AR
- Appeal Success Rate: 60% or higher
If your numbers are significantly off these targets, that’s when you know you need to take some action. It means there’s a specific stage of the workflow where things are breaking down, and identifying that stage is the first step toward fixing it.
The Tools That Make It Possible
None of this workflow happens in a vacuum. The reason high-performing billing teams can hit these benchmarks consistently is that they have tools that are integrated, automated, and designed to reduce manual touches at every stage.
Medisoft EDI handle eligibility automation, claim scrubbing, ERA posting, and denial reporting in a single connected ecosystem. Instead of toggling between platforms, manually importing files, or chasing down data from separate systems, everything flows through one integrated workflow. That integration is what makes it possible to keep claims moving quickly, catch problems early, and maintain the kind of disciplined process that translates into faster payments and a healthier AR.
Still working with a clearinghouse outside of Medisoft? Learn how Medisoft EDI is the smartest way to manage electronic claims in Medisoft. If you’re not sure how your current workflow measures up, or where the gaps might be, a financial assessment can help. It will allow you to see exactly where your revenue cycle is performing well and where there’s room to improve.
Need More Medisoft Training?
If you want to continue learning ways to get more out of Medisoft, we regularly host FREE Medisoft training webinars. These sessions cover helpful topics, new features, and workflow tips that can help your practice operate more efficiently. You can see all upcoming webinars by visiting our webinar events page.
Missed a webinar you were excited to see? No worries! You can access all our past webinars on our Medisoft University. If you have questions about Medisoft features, upgrades, or workflow improvements, feel free to contact our team.
About AZCOMP Technologies
AZCOMP Technologies is the #1 Medisoft reseller and support provider in the nation. Since 2000, we’ve been helping independent practices streamline their billing, improve patient collections, and get the most out of their software. From expert Medisoft support and training to full-service revenue cycle solutions, we’re here to make your practice more efficient, profitable, and stress-free.
