FAQs
Credentialing
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- It varies by payor and can be based on their backlog of applications. Typically, the process is between 60 and 120 days. It can sometimes take even longer. Commercial payors always tend to take the longest amount of time.
- The credentialing process duration can vary significantly depending on several factors, including the payer (Medicare vs. commercial insurance), the completeness of the application, the complexity of the provider's credentials, and the efficiency of the credentialing organization involved.
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- Initial Enrollment: The process for initial Medicare enrollment can take around 60-120 days or longer. This includes submitting the CMS-855 form and required documentation to the Medicare Administrative Contractor (MAC). Delays can occur if there are errors or missing information in the application.
- Revalidation: Medicare providers are required to revalidate their enrollment every few years. The revalidation process typically takes 60-90 days, although it can vary.
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- Application Completeness: Ensuring all required documents and information are submitted accurately and promptly can significantly impact how quickly the process moves forward.
- Verification Process: Verifying credentials, such as medical education, training, licensure, and work history, can take time, especially if there are discrepancies or delays in receiving verifications from third parties.
- Payer Requirements: Different payers may have varying requirements and processing times, which can affect how long credentialing takes with each specific insurer.
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- The credentialing application process for payors (insurance companies) typically involves several steps to verify and evaluate a healthcare provider's qualifications and eligibility to join their network. The application process with payors varies from state to state and payor to payor.
- Some payors support an online application process through Availity; some payors have an online portal for application submissions; and some payors still utilize a paper application to be completed as a PDF or by hand and submitted via mail or email. Medicare enrollment is standard across all states, completed via PECOS.
- With some payors utilizing CAQH data for credentialing purposes, providers must maintain and update their CAQH profiles as well.
- Credentialing is a critical task, and the costs can vary based on several factors – the current credentialing status, the number of offices within the practice, the number of providers, the number of payors, and the payor mix. The costs will vary from company to company but the level of service and detail also varies.
- Credentialing service providers typically charge for their services in various ways, depending on the complexity of the credentialing process and the specific needs of the healthcare provider or practice. Here are our methods of charging for credentialing services:
- Flat Fee: Many credentialing companies charge a flat fee for their services. This fee is often based on the type of provider (e.g., physician, nurse practitioner), the number of payers the provider needs to be credentialed with, and the complexity of the credentialing process. Flat fees provide transparency and clarity regarding costs upfront.
- Per Provider Fee: Some credentialing services charge on a per-provider basis. This means that each provider requiring credentialing is charged a specific fee. This method is straightforward for practices with a small number of providers or those adding providers sporadically.
- Hourly Rate: In some cases, credentialing services may charge an hourly rate for the time spent on each provider's credentialing process. This can be more flexible for practices with varying credentialing needs or those that require extensive support for complex cases.
- Additional Fees: There may be additional fees for services such as expedited credentialing, provider updates or changes, appeals for denied applications, or other specialized services. These fees are usually outlined in the service agreement or contract with the credentialing provider. We also provide other services such as CAQH enrollment, which is the online provider data collection tool as well as PECOS enrollment, which is the online Medicare database.
- To reduce costs, we can complete the applications and allow someone from your office to perform the follow-ups.
- Contact us to discuss pricing.
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- Yes, it is possible for someone from your team to assist in the credentialing process to help reduce costs to the practice or provider. Here are some ways your team member can contribute effectively:
- Data Collection and Organization: Your team member can gather and organize all necessary documents and information required for credentialing, such as medical licenses, certifications, malpractice insurance, DEA registration, education history, and work experience. This ensures that the credentialing service provider receives complete and accurate information promptly.
- Application Completion: They can assist in filling out credentialing applications and forms based on the information provided by the provider. This includes ensuring all required fields are completed correctly and any supporting documentation is included as needed.
- Follow-Up and Communication: Your team member can communicate with the credentialing service provider or directly with payers to follow up on the status of applications, provide additional information if requested, and address any questions or concerns promptly.
- Verification Assistance: They can help facilitate the verification process by ensuring that requests for information from third parties (such as medical schools, previous employers, or licensing boards) are submitted in a timely manner and responding promptly to any inquiries.
- Document Management: Maintaining a well-organized system for storing and accessing credentialing documents can streamline the process and reduce delays. Your team member can manage document storage and retrieval, ensuring that all documents are kept up to date.
- Quality Control: They can review completed applications and documentation for accuracy and completeness before submission to the credentialing service provider, minimizing the risk of errors or omissions that could delay the process.
- Yes, it is possible for someone from your team to assist in the credentialing process to help reduce costs to the practice or provider. Here are some ways your team member can contribute effectively:
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- Your team will need to be involved in the credentialing process mostly on the front end – gathering/organizing the necessary practice information, details on the practice setup, financial information, current provider information, etc. Once the necessary documentation and provider details are supplied to the Legacy team, your team can then have as little (or as much) involvement as you would like.
Commercial contracts between healthcare providers (such as physicians, hospitals, clinics) and insurance companies (commercial payers) typically outline how providers will be reimbursed for services rendered to patients covered by the insurance plan. Here are some common methods of reimbursement used in commercial contracts nowadays:
- Fee-for-Service (FFS):
- Description: Providers are reimbursed based on the fee schedule negotiated between the provider and the insurance company. Each service or procedure performed by the provider has a predetermined reimbursement amount.
- Variations: Fee-for-service arrangements can vary based on the complexity and type of service provided. Some fee schedules may be based on Medicare rates, while others may have proprietary fee schedules.
- Capitation:
- Description: Providers receive a fixed, per-member per-month (PMPM) payment from the insurance company for each patient assigned to them, regardless of the services provided.
- Payment Model: Capitation shifts financial risk to the provider, as they must manage patient care within the fixed payment amount. It incentivizes preventive care and efficient management of resources.
- Episode of Care/Bundled Payments:
- Description: Providers receive a single payment for all services related to treating a specific condition or for a defined episode of care (e.g., joint replacement surgery).
- Payment Structure: This model encourages coordination among providers and can lead to better care outcomes and cost containment.
- Pay-for-Performance (P4P) or Value-Based Reimbursement:
- Description: Reimbursement is tied to performance metrics related to quality of care, patient outcomes, and cost efficiency.
- Incentives: Providers may receive bonuses or penalties based on their performance compared to predefined benchmarks or quality measures.
- Shared Savings:
- Description: Providers share in the savings achieved by delivering care more efficiently than expected, compared to a baseline or target cost.
- Payment Mechanism: Savings are typically calculated as a percentage of the achieved cost savings relative to the baseline, with providers receiving a portion of those savings.
- Risk-Sharing Models:
- Description: Providers and payers share financial risk for the cost of healthcare services. This can include upside risk (shared savings) or downside risk (shared losses) depending on the performance against predefined targets.
- Global Payments or Capitated Payments:
- Description: Providers receive a lump sum payment to cover all healthcare services for a defined population over a specific period.
- Scope: Payments are often adjusted based on the health status and demographics of the covered population.
When considering whether to outsource credentialing for your practice, it's essential to make an informed decision. Here's some advice to help you evaluate the potential benefits:
Pros of Outsourcing Credentialing:
- Expertise and Efficiency:
- Credentialing companies specialize in navigating the complexities of credentialing processes, including various payer requirements and regulatory compliance. They can streamline the process, potentially reducing credentialing timeframes and minimizing errors.
- Time Savings:
- Outsourcing credentialing allows your providers and staff to focus more on patient care and practice operations, rather than administrative tasks.
- Cost Efficiency:
- While there is a cost associated with outsourcing, it can be cost-effective in the long run by reducing the administrative burden on your practice and potentially minimizing revenue losses due to delayed credentialing or errors.
- Compliance and Accuracy:
- Credentialing companies stay updated on the latest regulatory requirements and ensure all provider credentials are up-to-date and compliant, reducing the risk of compliance issues or denials.
- Network Expansion:
- Outsourcing credentialing can facilitate smoother participation in insurance networks and expedite provider enrollments with various payers, potentially enhancing your practice's ability to attract new patients.
If a new practice or a new location is told that a payor's network is "closed," it typically means that the insurance company is not currently accepting new providers into their network for that particular area or specialty. Here’s how to approach this situation:
- Understand the Reason for Closure:
- Reasons Vary: Network closures can happen for various reasons. It could be due to the insurance company reaching its desired provider capacity for that geographic area or specialty, or it might be related to specific network management strategies or financial considerations.
- Temporary vs. Permanent: Determine if the closure is temporary or permanent. Insurance companies periodically reassess their network needs, so a closed network might open up in the future.
- Explore Alternatives:
- Other Insurance Companies: If one payor has a closed network, explore contracting opportunities with other insurance companies that operate in the same geographic area. Not all insurers will have closed networks, so expanding your search can increase your chances of contracting.
- Different Plans or Products: Sometimes, a payor's network closure applies to specific plans or products only. Inquire if there are alternative plans or products within the same insurance company that might have open networks.
- Networking and Relationships:
- Network with Colleagues: Reach out to colleagues or peers who have contracts with the payor in question. They might have insights into network openings or strategies that could help navigate the contracting process effectively.
- Utilize Professional Organizations: Industry associations or professional organizations often provide resources and networking opportunities that can help in understanding contracting processes and finding solutions.
- Persistence and Communication:
- Follow Up: Even if initially told the network is closed, periodically follow up with the insurance company. Networks can change, and new opportunities might arise in the future.
- Build Relationships: Establishing a positive and professional relationship with the insurance company's provider relations or contracting team can sometimes open doors or provide insights into future opportunities.
- Evaluate Business Strategy:
- Patient Population: Consider the patient demographics in your area and their insurance coverage preferences. This can help prioritize which payors to target for contracting efforts.
- Long-Term Planning: If network closure persists, evaluate long-term business strategies that might involve diversifying services, expanding into different geographic areas, or adapting to changing payer landscapes.
Medical Billing
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- You should consider outsourcing your billing when you do not have the proper personnel to efficiently handle the required tasks to accomplish a seamless billing process from start to finish. Having the right person, effectively trained, to do the right job is key in ensuring timely and accurate reimbursement.
- Often times, the internal team is only handling the electronic billing process, but not working rejections and denials or doing proper claims follow-up to ensure the difficult claims get paid. When we assume the billing and collections for a practice, 95% of the time, we find that rejections are sitting and have not been worked, which represents cash that is not being collections. Likewise, if denials are not worked, claims will likely have to be written off over time. The follow-up process is time-intensive, but required to collect all the cash that belongs to the providers and the practice.
- Billing companies stay updated with changes in regulations and compliance requirements, reducing the risk of errors and potential penalties for non-compliance. Professional billing services often result in faster processing of claims and payments, leading to improved cash flow for the practice.
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- We typically invoice for medical billing and collections services on a percentage basis. If we are strictly tasked with working accounts to improve collections, we would invoice for a percentage of those collections. The typical range is from 4% to 8% but it depends on the size of the practice, the specialty, and whether or not we are handling all aspects of the billing process (from electronic billing to patient statements) versus just some of the tasks.
- Some of our services may also be billed at an hourly rate – such as initial billing process review, weekly and/or monthly reporting, regularly scheduled check-in calls – but that will be agreed upon up front with each client.
- Check out our Price Estimator Tool
Handling denials effectively is crucial for maintaining revenue flow and ensuring financial stability of a medical practice.
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- Identify the Reason for Denial: When a claim is denied, it’s essential to determine the specific reason for the denial. Common reasons include incorrect patient information, coding errors, lack of pre-authorization, or non-covered services.
- Review and Correct: Once the reason for denial is identified, take steps to correct the issue. This may involve reviewing the claim for accuracy, correcting any errors in coding or documentation, or obtaining additional information required for reimbursement.
- Appeal Process: Most denials can be appealed. Understand the appeals process of each insurance company and ensure appeals are filed promptly within their specified timelines. Include all necessary documentation and information to support the claim.
- Prioritize Denials: Prioritize denials based on their potential impact on revenue. Focus on high-dollar claims or recurring denial reasons that can have a significant financial impact on the practice.
- Track and Monitor: Implement a system to track and monitor denials. This helps identify trends or patterns in denials and allows the practice to address root causes proactively.
- Staff Training: Provide ongoing training to billing staff to stay updated on coding changes, insurance policies, and best practices for minimizing denials. This helps reduce future errors and denials.
- Utilize Technology: Use billing software or revenue cycle management systems that offer denial management features. These tools can streamline the appeals process, track denials, and provide analytics to improve billing efficiency.
- Communicate with Providers: Maintain open communication with healthcare providers or practice managers regarding common denial reasons and actions taken to prevent future denials. Collaborate on documentation improvements or coding practices to reduce denials.
- Monitor Metrics: Monitor key performance indicators related to denials, such as denial rate, turnaround time for appeals, and successful resolution rate. Use these metrics to evaluate the effectiveness of denial management strategies and make adjustments as needed.
- By implementing a structured approach to handling denials, medical practices can improve their revenue cycle management, reduce revenue leakage, and maintain financial health while ensuring timely reimbursement for services rendered.
Sending electronic claims typically speeds up the payment process significantly compared to paper claims. Here’s a general timeline of when you can expect to get paid if you send electronic claims:
- Initial Processing Time: Insurance companies typically process electronic claims faster than paper claims. For instance, BCBS and Medicare process a clean claim usually within 10-14 days. Upon receipt, they begin the initial processing, which includes verifying patient eligibility, checking for errors, and determining coverage.
- Adjudication and Approval: Once the claim passes initial processing, it undergoes adjudication. This is where the insurance company reviews the claim details, including services provided, coding accuracy, and any contractual agreements. If everything is in order, the claim is approved for payment.
- Payment Issuance: After adjudication, the insurance company generates a payment to the healthcare provider. Payments are often issued within a few weeks of claim submission, depending on the insurance company’s payment cycle.
- Electronic Funds Transfer (EFT): Many insurance companies offer electronic funds transfer (EFT) options for payment, which can further expedite the receipt of funds into the provider’s designated bank account.
Overall, electronic claims submission can significantly reduce the time it takes to receive payments compared to paper claims, which may take several weeks or even months. However, specific timelines can vary based on factors such as the insurance company’s processing policies, any additional reviews or audits required, and the completeness and accuracy of the claim submitted. It’s important for healthcare providers to monitor claim status and promptly follow up on any delays or denials to ensure timely reimbursement for services provided.
Our team is able to provide services from start to finish of the billing process – charge entry, working rejections, working AR, payment posting, denials, patient statements, etc. We can review your practice on the front-end and make suggestions on how to improve your current processes.
As a medical billing and collections outsourcing provider, the services typically offered can encompass a wide range of functions aimed at managing the revenue cycle effectively for healthcare practices. Here are the primary services commonly provided:
- Insurance Verification and Eligibility (if requested): Verification of patient insurance coverage, eligibility, and benefits prior to services being rendered to ensure proper billing and reduce claim denials.
- Claims Submission: Preparation and submission of medical claims to insurance companies, Medicare, Medicaid, and other third-party payers electronically or via paper as necessary.
- Payment Posting: Recording and reconciliation of payments received from insurance companies and patients against outstanding balances to maintain accurate accounts receivable records.
- Denial Management and Appeals: Identification, analysis, and resolution of claim denials through appeals processes to maximize reimbursement and minimize revenue loss.
- Accounts Receivable Follow-Up: Proactive follow-up on outstanding claims and aged accounts receivable to expedite payment and reduce the average days outstanding (DSO).
- Reporting and Analytics: Provision of regular reports and analytics related to billing performance, revenue trends, claim denials, and collections metrics to support practice management decisions.
- Patient Billing and Invoicing: Generation and distribution of patient statements for services rendered, including handling inquiries related to patient billing and payment arrangements.
- Credentialing Services (separate scope of work but available to all clients): Assistance with provider credentialing and enrollment with insurance networks to ensure providers can bill and receive payments from various payers.
- Compliance and Regulatory Support: Adherence to healthcare regulations (HIPAA, Medicare/Medicaid guidelines, etc.) and staying updated with industry changes to maintain compliance in billing practices.
- Consulting and Support Servicse (usually billed at an hourly rate): Guidance and support on revenue cycle optimization, coding audits, fee schedule analysis, and process improvement initiatives to enhance overall billing efficiency and revenue generation.
Providers of medical billing and collections outsourcing tailor their services based on the needs and preferences of the healthcare practice, aiming to streamline operations, improve cash flow, and optimize revenue while allowing providers to focus on patient care.
Legacy, as a medical billing and collections outsourcing company, supports a wide range of provider specialties across the healthcare spectrum. While the specific list may vary depending on the company's capabilities and expertise, here are common provider specialties that Legacy supports:
- Primary Care Physicians (PCPs): Family medicine, internal medicine, pediatrics, etc.
- Specialty Care Physicians: Cardiology, dermatology, gastroenterology, neurology, oncology, etc.
- Surgical Specialties: General surgery, orthopedic surgery, urology, etc.
- Hospital-Based Practices: Anesthesiology, emergency medicine, radiology, pathology, etc.
- Mental Health and Behavioral Health: Psychiatry, psychology, counseling services, etc.
- Women's Health: Obstetrics and gynecology (OB/GYN), reproductive medicine, etc.
- Dental and Oral Surgery: General dentistry, endodontics, periodontics, orthodontics, etc.
- Chiropractic Care: Chiropractors and related services.
- Physical Therapy and Rehabilitation: Physical therapy, occupational therapy, speech therapy, etc.
- Home Health and Hospice: Home health agencies, hospice care providers, etc.
- Home Care Services: in-home care assistance, respite, etc.
We support healthcare facilities such as hospitals, clinics, urgent care centers, imaging centers, and laboratories, among others.
Each specialty and healthcare setting has its unique billing and coding requirements, compliance considerations, and reimbursement challenges. We tailor the services to meet the specific needs of each provider specialty, ensuring efficient revenue cycle management and compliance with healthcare regulations.
Effective communication between Legacy and the healthcare provider's office is crucial for smooth operations and accurate billing. Here are common methods and practices for communication:
- Electronic Health Records (EHR) Integration: We can integrate directly with the provider's EHR system. This allows for seamless access to patient demographics, encounter notes, and coding information without manual transfer, ensuring accuracy and efficiency.
- Secure Messaging Platforms: Utilizing secure messaging platforms or portals for communication ensures that sensitive patient information and billing details are transmitted securely with the provider's office.
- Regular Meetings or Calls: Scheduled meetings or conference calls between the billing company and the provider's office can facilitate discussions on billing issues, updates on claim statuses, and addressing any concerns or questions promptly.
- Email Communication: Email is often used for routine communications or general inquiries.
- Phone Communication: Direct phone calls may be used for urgent matters or complex issues that require immediate attention or detailed discussion.
- Training and Documentation: Providing training sessions or documentation to the healthcare provider's office staff on best practices, coding updates, and compliance requirements ensures clear communication and understanding of billing processes.
- Follow-Up Protocols: Requests for additional information or actions are tracked through Excel and access to Sharepoint online, which ensures that items are responded to promptly, minimizing delays in billing and collections.
By establishing effective communication channels and practices, we can maintain a collaborative relationship, ensuring accurate billing, timely reimbursement, and overall satisfaction with billing services.
Revenue Cycle Management
Our medical billing services stand out from other outsourced vendors and practice management system providers by offering tailored solutions backed by deep industry expertise. Our proactive denial management strategies and compliance expertise ensure minimal disruptions and maximum revenue capture. We combine advanced technology with personalized service to optimize revenue cycles and ensure compliance, from coding accuracy to seamless integration with your existing systems. With a focus on transparency, proactive support, measurable results, and dedicated Revenue Cycle Specialists, we empower practices to thrive financially while delivering exceptional patient care.
Feel free to read About Us and learn more about the Owner several of our team members.
Revenue Cycle Management (RCM) Basics
- Definition: Revenue Cycle Management (RCM) refers to the financial process of managing the healthcare revenue cycle, which encompasses all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue. It involves the entire lifecycle of a patient account from initial appointment scheduling or registration to claims submission to final payment of the balance.
- Key Components: Patient registration, insurance verification and authorization, charge capture, coding, claims submission, payment posting, denial management, AR follow-up, revenue analysis, and reporting.
- Importance: Effective revenue cycle management is essential for healthcare organizations to optimize financial performance, ensure regulatory compliance, and maintain operational efficiency. It aims to maximize revenue capture, reduce billing errors and claim denials, accelerate payment cycles, and ultimately support the delivery of high-quality patient care by ensuring financial stability.
- Address Common Challenges in RCM
- Billing Errors: Minimize billing errors through billing and compliance checks.
- Denial Management: Address claim denials and appeal successfully when they occur.
- Cash Flow Optimization: Accelerate revenue cycles and improve cash flow predictability.
- Provide Benchmarks and Metrics
- Key Performance Indicators (KPIs):
- Days in Accounts Receivable (AR): Average number of days it takes to collect payments.
- Collection Rate: Percentage of billed charges and net revenue collected.
- Denial Rate: Percentage of claims denied.
- First-Pass Payment Rate: Percentage of claims paid on first submission.
- Industry Standards: Compare performance against industry benchmarks to demonstrate improvement opportunities.
- Customized Reporting: Offer tailored reports that track KPIs over time, showing tangible outcomes of your services.
- Key Performance Indicators (KPIs):
- Educational Resources and Support
- Training Workshops: Conduct workshops or webinars on RCM best practices, compliance updates, and revenue optimization strategies.
- Consultative Approach: Provide personalized consultations to address specific RCM challenges and opportunities.
Our RCM services streamline billing processes, reduce administrative burden, and improve revenue capture through meticulous coding, claims submission, and payment posting. We leverage advanced technology to enhance accuracy and compliance, ensuring faster reimbursements and increased financial predictability for your practice.
We track key metrics such as Days in Accounts Receivable (AR), Collection Rate, Denial Rate, and First-Pass Payment Rate. These metrics help us gauge operational efficiency, identify areas for improvement, and compare your practice’s performance against industry benchmarks. Our customized reporting provides clear insights into revenue cycle health and actionable strategies for optimization.
What differentiates us from any other outsourced medical billing vendor or practice management system vendor offering revenue cycle management or medical billing services?
We will highlight the key advantages and unique selling points that address the specific needs and pain points of your medical group or organization.
- Tailored Solutions and Expertise
- Detailed Assessment: Conduct a thorough analysis of RCM processes, identifying specific pain points, recommending areas for improvement and assisting with implementation, as needed.
- Customization or Tailored Strategies: We tailor our services to meet the unique needs of each medical practice, whether they are small clinics or large healthcare systems.
- Specialized Expertise: Our team’s deep knowledge and experience in medical billing, including specialized areas such as coding compliance, specialty-specific billing, and insurance claim processing sets us apart from other vendors.
- Comprehensive Service Offering
- End-to-End Services: We offer a comprehensive range of services beyond basic billing, such as coding, claims management, denial management, revenue cycle analytics, and patient billing.
- Full Lifecycle Support: Our team can manage the entire revenue cycle from patient registration to payment posting, basically as little or as much as you need us to handle.
- Proactive Denial Management and Revenue Cycle Optimization
- Early Detection and Prevention: Implement proactive denial management strategies to identify and address potential issues before claims are submitted.
- Analytics and Reporting: Provide comprehensive analytics and reporting dashboards that offer insights into revenue cycle performance, allowing practices to make data-driven decisions.
- Compliance Expertise, Risk Mitigation and Revenue Optimization
- Compliance Assurance: We assure adherence to healthcare regulations (e.g., HIPAA) and coding guidelines to minimize audit risks and penalties.
- Revenue Maximization: Highlight strategies to optimize revenue capture, reduce claim denials, and accelerate payment cycles through proactive management and analytics.
- Personalized Customer Support and Transparency
- Dedicated Account Management: At Legacy, we offer personalized customer support with dedicated Revenue Cycle Specialists who understand the specific needs and challenges of each practice.
- Transparent Reporting: It is important to provide clear, actionable reports and analytics that empower practices with insights into financial performance and operational efficiency.
- Performance Metrics and Outcomes
- Measurable Results: Showcase proven results and key performance indicators (KPIs) that demonstrate improvements in AR days, collection rates, denial rates, and overall revenue cycle health.
- Testimonials: Client testimonials illustrate successful partnerships and outcomes achieved through our services.