Medical Billing Is Not One Job. It Is Six Different Ones.
Medicare bills to one of 12 MACs under federal rules. Medicaid bills to 56 state programs and their contracted MCOs with state-specific timely-filing windows. Medicare Advantage bills to private plans with HCC-driven risk adjustment. Commercial insurance bills under ERISA or state-DOI rules depending on funding. Workers' comp bills under state-specific fee schedules. Self-pay bills the patient directly under the No Surprises Act Good Faith Estimate framework. Each payer category requires a different operational discipline.
- Medicare: federal program, 12 MACs, 365-day timely filing
- Medicaid: 56 state programs, ~70% in managed care, EVV required for personal care/home health
- Medicare Advantage: 33+ million enrolled, plan-specific PA, HCC recapture annually
- Commercial: ERISA self-funded vs state-DOI fully-insured, federal IDR for OON NSA claims
- Workers' comp: 50 state systems plus FECA/LHWCA, state fee schedules, lien filings
- Self-pay: GFE required since 1/1/2022, $400 dispute threshold, payment plans
Every Payer Has Different Rules.
We Know All of Them.
Choose your payer category to see how we handle the specific submission rules, prior-authorization gates, and reimbursement mechanics that govern that payer's claims.
Payer Categories We Bill
Six payer categories cover virtually all medical-billing volume in the United States. Each has its own rulebook.
Medicare Billing Services
Part A/B claim submission to MAC jurisdictions, LCD/NCD compliance, ABN workflows, MSP coordination, and QMB crossover handling.
See How We Bill This Payer arrow_forwardMedicaid Billing Services
50-state MMIS submission, MCO claim routing, EVV compliance under the Cures Act, and HCPCS T-code billing for state-specific services.
See How We Bill This Payer arrow_forwardMedicare Advantage Billing Services
Plan-specific submission, prior-authorization gates, HCC capture for risk-adjusted panels, and supplemental-benefit billing routing.
See How We Bill This Payer arrow_forwardCommercial Insurance Billing Services
UnitedHealthcare, Aetna, Cigna, BCBS, Humana — ERISA versus state-DOI appeals, PA matrices, and federal IDR for No Surprises Act claims.
See How We Bill This Payer arrow_forwardWorkers' Compensation Billing Services
State-specific fee schedules, employer/carrier coordination, utilization-review submissions, IME reports, and lien filings.
See How We Bill This Payer arrow_forwardSelf-Pay and Patient Billing Services
Good Faith Estimates under the No Surprises Act, patient statements, payment plans, and financial-assistance application processing.
See How We Bill This Payer arrow_forwardWhy Payer-Specific Billing Discipline Matters
A practice that defaults to a single billing workflow across every payer category systematically writes off recoverable revenue. The Medicare timely-filing window is 365 days; the New York Medicaid window is 90; a UnitedHealthcare commercial product may be 90 to 180 days; a workers' comp claim in California has its own statutory window. One billing operation, six different deadlines.
The same fragmentation runs through prior authorization, fee schedules, appeals processes, and patient-billing rules. Medicare Advantage applies PA gates to services traditional Medicare adjudicates without auth. ERISA self-funded plans use federal §503 appeal processes; state-fully-insured plans use state-DOI external review. Workers' comp claims pay under state fee schedules tied to a percentage of Medicare in some states and proprietary tables in others. Self-pay billing now runs through the No Surprises Act Good Faith Estimate framework with patient-provider dispute resolution above the $400 threshold.
Specialty-based and service-based billing pages organize around what the practice does. Payer-based billing pages organize around what the practice gets paid for. Buyers searching by payer name — "Medicare billing services," "Medicaid billing for home health," "workers' comp billing in California" — are evaluating whether a billing partner has the operational depth in that specific payer category to clear the rules cleanly.
Get a Payer-Specific Billing Review
Tell us which payer mix is leaking revenue, and we will show you where the recoverable money sits.