A four-physician practice we spoke with in May has had a biller position open since January. The two remaining billers are posting payments and submitting claims. Nobody is working denials older than 60 days, the clearinghouse rejection report is checked "when there is time", and the practice manager is doing eligibility checks herself between everything else. The practice is not badly run. It is short one person and the revenue cycle does not shrink to match.
This is the normal condition of independent practices in 2023. An MGMA Stat poll on March 21, 2023 asked practice leaders which revenue cycle roles were hardest to hire: medical coders were the most common answer at 34%, billers second at 26%, then schedulers at 18% and authorization staff at 15%. MGMA's 2023 practice operations data put turnover in 2022 at 40% for front office staff and 33% for business operations support staff, the category that includes billing. Its polling has put staffing at the top of practice leaders' challenges for the third year running. Wages are up and so is everything else the practice buys.
Key takeaways
- Rework (rejections, denials, corrected claims, payer calls) is the largest block of billing time and the only one that is almost entirely avoidable.
- Five clean-claim habits and six automations, most of them configuration in systems you already pay for, recover the equivalent of a part-time position in many practices.
- A team of two or three has no redundancy; write the payer quirks down and make sure two people can do every task.
- Outsource the specialized, episodic pieces (denials, credentialing, old AR, coding review) and keep patient contact in house.
- Growing billers from medical assistants and front-desk staff takes months and a training budget, and it is working better than recruiting this year.
Where the hours actually go
Before deciding what to change, measure what the team does. In the billing offices we audit, the time splits roughly like this: a third on rework (rejections, denials, corrected claims, payer calls), a quarter on posting and reconciliation, a fifth on eligibility and authorization, and the rest on charge entry, statements and questions from the front. Rework is the largest block and the only one that is almost entirely avoidable. A claim that is right the first time costs a few minutes. A claim that is denied and reworked costs, by most industry estimates, somewhere around $25 in staff time, and the number is higher when the payer has to be called. Cutting the denial rate from 10% to 6% on 2,000 claims a month removes 80 pieces of rework, which is a week of one person's time.
Measure it for two weeks with a simple tally: each biller marks a sheet with the category of every task they touch. It is crude and it is enough. Every practice that has done this with us has been surprised by one number, usually the payer phone time, and that surprise is what gets the automation budget approved.
Clean claim habits that remove rework
- Eligibility and demographics before the visit, so registration errors (CO-31, CO-16 with a subscriber ID remark) do not exist to fix. Most rejections we see at the clearinghouse are registration errors.
- Scrubber edits tuned to your top denials. Every practice management system has claim edits; few practices maintain them. Take the top ten denial reasons from the last quarter and make sure an edit catches each one before submission. Modifier 25 without a same-day procedure, missing NDC on drug lines for Medicaid, invalid diagnosis pointers, a rendering provider not enrolled with the payer.
- Same-day note signing. Charge lag is not only a cash flow problem; late charges arrive after the coder has moved on and get less attention.
- A daily rejection report review, first task of the morning, fifteen minutes. Rejections are the cheapest fix in the cycle because the payer has not seen the claim yet.
- Denials sorted by dollars and deadline, not by date received. A team of two cannot work every denial; it can work the ones that are worth it and time-limited.
What to automate, what to keep human
| Task | Automate | Keep with staff |
|---|---|---|
| Eligibility | Batch 270/271 two days before every visit, exceptions flagged | The phone call to the patient about the exception |
| Claim status | 276/277 status inquiries at 14 and 30 days for unpaid claims | Follow-up on claims the payer shows as pended or not on file |
| Payment posting | Electronic remittance (835) auto-posting for every payer that offers it | Exceptions, takebacks, and underpayment review against the contract |
| Patient statements | Statement cycle triggered by posting date, electronic delivery, online payment | Payment plans and hardship decisions |
| Denials | Categorization by CARC and RARC, work queues by dollar and timely filing date | Appeals, peer-to-peer coordination, root cause fixes |
| Prior authorization | Requirement check at scheduling from the payer's current list | Submitting the clinical information and chasing the decision |
Most of this is configuration in systems the practice already pays for, not new software. Enrolling in electronic remittance with every payer and turning on auto-posting is often the single largest time saving available, and we still find practices posting paper remittances from national payers in 2023. Enrolling in electronic funds transfer at the same time removes the trip to the bank and the lost checks.
A worked example: two billers, 1,600 claims a month
A fictional internal medicine practice with three physicians and two billers submits about 1,600 claims a month. The tally shows the billers spend about 90 hours a month on rework, 60 on posting, 40 on eligibility and authorization, and the rest on everything else. The denial rate is 11%, and 40% of remittances are still posted by hand from paper or portal downloads.
Three changes over one quarter: electronic remittance and auto-posting with the six payers that were still on paper, which cuts posting time roughly in half; a batch eligibility run with an exception list, which removes most of the CO-31 rejections and the day-of scramble; and five scrubber edits built from the top denial reasons, which moves the denial rate toward 7%. The result is somewhere around 70 to 80 hours a month returned to the two billers, which is the open position's hours without the open position. The practice still wants a third biller. It can now wait for the right one instead of hiring the first one.
Cross-training and coverage
A billing team of two or three has no redundancy. When one person leaves, the knowledge of "how we bill for payer X" leaves too. Write down the payer quirks in one shared document, make sure at least two people can post payments and two can work rejections, and have the front desk trained to read a 271 response. Remote billers widen the hiring pool considerably; the work is portable and the tools are web-based, and the practices filling roles fastest this year are the ones that stopped requiring the biller to sit in the building.
Deciding what to send out
Outsourcing is not all or nothing. The pieces that fit a shortage best are the ones that are specialized and episodic: denial follow-up and appeals, credentialing, old AR cleanup, and coding review. Keeping charge entry, posting and patient contact in house while a partner works denials is a common arrangement, and it keeps the practice's knowledge of its own patients where it belongs. If the whole function goes out, the practice still needs one person who owns the relationship, reads the monthly report and pushes back.
The question to ask before either choice is what the open position is costing now. A biller vacancy of six months, with denials aging past timely filing at 90 or 180 days, usually costs more in written-off claims than the salary. Put a number on it: count the denials in the queue older than 60 days, total their dollar value, and estimate the share that will pass the payer's appeal or timely filing limit before anyone touches them. That is the number to put in front of the physicians.
Growing your own
Experienced coders and billers are scarce, and the hiring market is not going to loosen this year. The practices we see doing best are training medical assistants and front-desk staff into billing roles, with structured coursework and a supervised period. That takes a few months and a training budget. It also produces staff who understand the front end of the cycle, which experienced hires from other practices often do not. The Revelrex RCM courses and the training EHR exist for exactly this path; we built the simulation lab because reading about a 271 response is not the same as working one.
Questions we hear
Should we raise biller pay to compete?
Probably, and it may still not fill the role. Pay fixes retention more reliably than recruitment. Look at your turnover first; if the practice is losing billers every eighteen months, the cost of replacing them is higher than the raise.
Which metric shows whether the changes work?
First-pass acceptance rate (claims accepted and paid without rework) and days in AR. If first-pass acceptance rises and AR days fall with the same headcount, the team has more time than it did. If not, the rework is still there and something in the list above is not running.
Can Revelrex take part of the work?
Yes. Denial management and credentialing are the pieces practices most often hand to us while keeping the rest in house, and the scope is written into the service order so both sides know who does what.
What to do this month
- Run the two-week task tally with the billing team and total the hours by category.
- List every payer still sending paper remittances or requiring portal downloads and enroll each in 835 electronic remittance and EFT.
- Pull the top ten denial reasons from the last quarter and build or fix a scrubber edit for each.
- Count and value the denials older than 60 days and present that number, next to the open position's salary, at the next physician meeting.
- Write the payer quirks document and confirm two people can perform each of posting, rejections and eligibility.
