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Getting paid in private practice

3 min read

Private-practice revenue is a workflow, not an event. Contracting, credentialing, documentation, coding, claims, denials, patient balances, and cash reconciliation all have to connect.

THE REVENUE CYCLE

The AMA maps eight linked steps: patient registration; insurance verification; check-in and check-out; medical billing and coding; claim preparation and submission; monitoring payer decisions; preparing patient bills; and managing payments and collections. A mistake early in the chain can become a denial or a delay weeks later.

Contract & credentialChoose the payer mix, model negotiated rates and obligations, complete enrollment, and confirm the effective date before assuming a claim is payable.
Document & codeClinical documentation must support diagnosis and service codes. CPT is HCPCS Level I; CMS maintains HCPCS Level II for supplies and services not included in CPT.
Submit & work denialsValidate demographics, coverage, authorization, modifiers, units, and identifiers; then assign owners and deadlines for rejected and denied claims.
Post & collectReconcile remittances, adjustments, patient responsibility, refunds, and deposits so the bank balance matches the ledger.

For Medicare, the practice needs the correct NPI and enrollment path. CMS directs individual physicians and non-physician practitioners to CMS-855I and clinics or group practices to CMS-855B, with PECOS available for online submission. Medicare enrollment is not the same as a commercial payer contract, and payer effective dates and filing rules differ.

1 calendar yearMedicare professional-claim filing deadline after date of service, with limited exceptions
QuarterlyAMA's suggested cadence for a full revenue-cycle review

At minimum, review charge lag, claim acceptance, first-pass resolution, denial rate and reasons, days in accounts receivable, aging by payer, net collection, patient balances, and cash collected against the forecast. Use payer-specific deadlines—not Medicare's rule—as the calendar for commercial and Medicaid claims.

Outsourcing does not remove ownershipA billing company can execute the work, but the practice still needs access to its contracts, fee schedules, claims, remittance data, denial queues, bank deposits, and performance reports. Define service levels, data ownership, termination rights, security duties, and audit access in writing.

Your next steps

  1. Build a payer matrix: enrollment owner, application date, effective date, contract rate, authorization rule, and filing deadline.
  2. Map who owns each of the eight revenue-cycle steps and what happens when a claim fails.
  3. Run a weekly cash forecast using expected collection timing—not billed charges.

Check your understanding

Select each question to reveal the answer.

✓ Before the visit, with registration, insurance verification, payer contracting, and credentialing.
✓ CMS-855I for an individual physician or practitioner; CMS-855B for a clinic or group practice.
✓ Complete clinical documentation connecting the diagnosis and services furnished to the codes billed.
✓ No later than one calendar year after the date of service, subject to limited exceptions.

Planning questions

  1. Which payers will you contract with first, who owns each enrollment, and what effective date and filing deadline applies?
  2. What are your target and alert levels for claim acceptance, first-pass resolution, denials, days in accounts receivable, and weekly cash on hand?

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