Outside Biller: Evaluating services to find the best fit – Part 2

Outside Biller: Evaluating services to find the best fit – Part 2

Last time, in Part 1 of the series, I discussed the choice of outsourcing vs. doing your own billing.  That decision may be the cornerstone of your practice’s success.

How do you choose from the hundreds of outside biller services?  

Many of the inquiry calls I receive fall into one of two scenarios.

In one, a clinician calls and only asks what I charge. While it is important to have a budget, price is only one of many important considerations. Remember – a biller has the power to make your business succeed or fail. With that in mind, choosing the lowest bidder may be a risky move.

Alternatively, therapists tend to be friendly people and use emotion to guide decisions. The second type of caller generally chats with me about billing, hoping to feel comfortable and establish a relationship. Being friendly with your biller is nice and will definitely help to build trust. 

Trust is important – this person will be handling your money! But aside from the trust factor, a strong personal relationship does not guarantee billing competence.

I suspect the main reason I don’t get more interview questions is because clinicians don’t know what to ask a potential biller, aside from the cost. After all, if you knew about billing, would you need an outside service? 

So, my goal here is to help you to identify critical factors in the choice of the right company or individual for YOU.*

*Note: I understand some clinicians consider the venture capital firms (Alma, Headway, etc), to be “billing services.”  I’m not going to discuss these options here. Their offerings differ enough from billing services to make side-by-side comparisons impossible. 

Other reasons include the future impact these firms might have on private practice. I am currently researching this topic and possibly will write about it at another time.


5 Questions to ask a billing service when looking to outsource


How much is this gonna cost?

This first question really should be the last!
There’s an enormous variety of services and packages out there.

The price quoted will depend on multiple factors.

Let’s take a look.
  • Their technology expenses
  • Labor costs
    • US employees only?
    • Virtual, in-office, or hybrid?
    • Outsourcing offshore? To what extent?
    • Employee level of expertise (certifications & experience? or relatively new?)
  • Specialty of the billing company
    • Billers typically charge more for certain specialties than others.
      • Mental health billers will submit many more claims but receive a much lower reimbursement per claim than surgical billers, for instance.
      • A billing company offering multiple specialties may have a different price structure than a biller who only handles mental health.
  • Geography and Compliance
    • What is considered a “reasonable” fee to charge where the biller is located?
    • What is the average fee where you are located?
    • The prevalence of virtual work means that your biller might not be local to you.
      • What is the average fee where the remote biller is located?
      • If there is a discrepancy, the costs in both areas should be considered.
    • Check your local laws: 
      • Some states have banned percentage-based billing fee structures. Others only prohibit it for Medicaid funds but it’s ok for commercial policies.
        • Do your research. This article is a good place to begin that process.
        • Choosing a biller that operates against the laws of your state could jeopardize YOUR license! 
      • Does your state require certification/licensing of billing companies? 
        • For instance, some states (such as Arizona) require billing companies to be licensed as collection agencies.  
        • A few states even charge sales tax on billing services!
      • Does the biller understand the payers, quirks, and laws of your state/location? 
        • If not, are they willing to learn?
        • Will you need to pay for their learning curve?
      • Ask questions about their HIPAA and OIG compliance plans, activities, training, and monitoring. A reputable service that pays attention to compliance will not mind sharing this information with you.
  • Pricing arrangement: there are many ways to pay a billing service for their work!
    • Percentage
    • Hourly
    • Per project
    • Per claim or clinical encounter
    • Packages
    • Flat monthly fee
      • With or without tiers to accommodate more or fewer clinical hours in any given month?
    • Implementation fees?
    • Minimum fees?
    • Do denials and clawbacks affect what you pay your biller?
    • Add-on charges (software access; postage; electronic transactions) ?
    • Will there be any price variations that result in expenses higher than expected?
      • If yes, what factors cause the variations?
      • Are these factors under your control, or not?

When you are quoted a price – high OR low – ask about ALL services that are (or are not) included. If you intend to compare different companies/solutions on price, they need to be offering the same features, or your comparison will be meaningless. 


What software does the outsourced billing company use?

use yours or the billers softwareWill the billing company use their platform, or yours?

If they use yours:

Is it an effective product for billing?

Many of the commonly-used do-it-yourself EHR systems are better for clinical applications, than for billing. (I realize that this opinion of mine might not be popular…)

If the biller uses their product:

  • Can my current EMR be integrated?
  • If no: do they have an integrated EMR / should I switch to theirs?
    • If I do, what happens to my clinical records if I change billers?
  • Does their integrated EMR handle mental health to my satisfaction?
  • Is their integrated EMR easy for me to use?

If your clinical EMR does not integrate at all with the biller of your choice:

  • Will you have access to the biller’s software? Read-only or editable?
  • Who does charge entry? Payment posting?
  • What (if any) role will the biller have in your clinical system? 
    • How does this impact what you pay for your system?

Some billers will work on any platform requested. Others will only work with programs they think will deliver the best outcome.  The right answer is what works best for both the therapist and biller – and gets you PAID!


Does the billing company offer the services you need? 

In Part 1, I introduced the concept of revenue cycle management and listed the many functions necessary to achieve profitability.

  • Does the prospective outside biller offer a suite of services closely aligned with what you need? services
  • Are add-on services possible?
  • Is it possible to decline RCM functions you do not need?
  • If you add or decline options, how does this affect your costs?
  • If you only need one or two functions, will the company accommodate this?

Clinicians who inquire about services typically are surprised when I spend significant time assessing their needs. Yes, it’s time-consuming. But having such conversations before signing a contract is the best way to ensure a good fit and a fair price. 


Does their size, structure, and account management workflow meet your needs?


A smaller outside biller can be appealing. More individualized attention!

But there is a downside. What happens if a key person is unavailable? (vacation, illness, etc).

On the other hand, a large firm might not provide you with enough personalized attention.

The only right choice is what works best for YOU!



Who will handle my practice? 

  • Just one person? 
  • A small team or department? 
  • Is it an assembly line model? (One team for each RCM function, handling all accounts.)

Who do I contact if issues arise?  

Is the owner/management responsive? Receptive to my feedback?  How much flexibility will I have to request alternative arrangements if I am dissatisfied?


Is the billing company a specialist in mental health? 

In 2023, billing for behavioral health is no longer as different from medical specialties as it used to be. But, there are still quirks that set us apart. The important question for you to ask is: how much experience has the biller had with behavioral health?

Mental Health Team

There is absolutely NOTHING wrong with using a larger, multi-specialty billing service. Many billers I respect are the owners of larger firms. I wouldn’t be the biller I am today if I hadn’t had those colleagues to learn from. 

Whether your RCM company bills only for mental health will be a matter of personal preference. Presumably, after you have taken into account all other considerations.


In the end, what matters most is that whoever you hire gets the vast majority of your claims PAID! 

Want to try it on your own? Join me for Part 3 – How to be Successful doing your own billing.

Hire A Biller? Which way to go?! – Part 1 of 4

Hire A Biller? Which way to go?! – Part 1 of 4

I’m often asked whether it’s better for therapists to hire a biller or to do it themselves. 

Happy to help with this and other related questions!

But…there is a problem…  Therapists tend to expect a definitive yes or no answer. 

I find this strange. As a therapist, would you tell your client what they should do? 

Yet, clinicians seem to expect that my advice regarding whether to hire a biller is a one size fits all proposition. 

Sorry. It’s just … not that simple. 

In fact, there is so much complexity in answering this question that I am going to take FOUR blogs to address it! 

Part 1 – Hire a biller or do my own? Overview.
Part 2 – Outside biller: evaluating services to find the best fit.
Part 3 – How to be successful doing your own billing.
Part 4 – How to evaluate billing software. This is critical regardless of who the biller is. 

Should I hire a biller?

Which resource do you have more of – time or money?  Let’s look at both.


Billing takes time! There’s no getting around it.

Claim submission is no longer time-consuming, thanks to online EMR/practice management (PM) platforms.  But if by “billing” you are thinking of claims submission, that alone won’t make your practice profitable. What is needed for profitability is revenue cycle management (RCM).

Say what?

RCM is the fancy industry term that describes ALL the activities needed to ensure a practice’s profitability: 

    • Obtaining correct, complete intake information (including insurance cards)
    • Eligibility/benefit verification
    • Claims submission
    • Review rejected claims, correct, and resubmit
    • Posting of paid, denied, and deductible claims
    • Dispute/appeal denials or underpayments, and follow up – often repeatedly! 
    • Follow up on claims that disappear/stay pending too long
    • Reconcile remittances with banking
    • Challenge clawbacks
    • Manage patient balances, which can include multiple tasks:
      • Invoicing
      • Charging credit cards
      • Out of network superbills
      • Discussing balances / deductibles in a therapeutic manner, developing payment plans as needed.
    • Ensure provider enrollment stays current, correct, and matches claim submission 
    • Stay on top of the numerous payer rules that affect your practice
    • ….REPEAT!

And that’s in addition to doing your clinical notes. Because you can not submit claims until those notes are done!!  If you are – STOP! NOW! Talk to me if you need to know why.


Exhausted yet?


Hire a biller

It’s more manageable than it sounds.
However, you must have the time and the right ingredients.




In my experience, these are:

It may not be the…

  • cheapest product
  • one “everyone” uses.
  • most visually appealing

It’s the one that has the best mix of features, usability, support, and affordability FOR YOU. There is no “perfect” program out there!

  • Organization / setting up a good workflow and sticking to it
  • Patience – LOTS of patience!
  • Frustration tolerance
  • Attention to detail
  • An interest in problem-solving
  • Compartmentalize your emotions 
    • Meaning?  YES, insurance is awful, a mess, etc. I’m sure I’ve used every adjective and four-letter word you are thinking of right now! (and probably more…)
    • But if you’re going to deal with it, you will be successful IF -and only IF- you can learn to put those attitudes and emotions to the side while you concentrate on getting the job done. Afterward…go to the gym and hit a punching bag!  (Or don’t take insurance).
  • Willingness to learn new skills
  • patience when it comes to billingInsurance basics
  • Technology
  • You don’t need advanced math, but are you willing to deal with numbers?
  • …and did I mention patience?

Good billing services, virtual assistants, or W2 employees are not cheap.  I understand that it can be tempting to go for the cheapest solution. But too often, I’ve had desperate clinicians interviewing me on the phone, in tears because a bad biller has cost them thousands, even tens of thousands of dollars. They ask how much of that back revenue I can collect for them. The answer is dependent on the payers, the specific scenarios, and most importantly the age of the claims, but is usually only a fraction of what they are owed, possibly less than 50%. Is saving money on a biller worth losing that kind of revenue?  In the end, do you come out ahead?

Finding the right person – or team – is critical!  

This is your income! 

If the person you hire does not do a good job, how will you pay the rent – or YOURSELF? 

So how much does it cost?

Whichever way you go, it’s significant. It may even be the single most expensive item in your operating budget.  But if the biller you hire collects 95% or more of the income that you have worked so hard for, then isn’t it worth it?  (95% is a realistic expectation, in my experience.)

What are your choices?


Part-time vs full-time? How much above minimum wage are you able to pay? Consider taxes, health insurance, and other benefits (vacations/paid time off, retirement-401K, productivity bonuses, etc). Plus the cost of payroll and related services. Also, consider that you will need time and energy to train and manage an employee.  Can you provide working conditions that will attract good talent?

If you are considering a 1099 contractor instead of an employee, can you be sure you meet the IRS classification for contractors vs an employee? If you mis-classify an employee as a contractor, you could be liable for hefty tax penalties.

Either way, are you able to monitor effectively without micro-managing? How will you provide needed training or supervision?


Does the service charge a percentage* of your income?  Other possible ways billers can charge: per transaction, per hour, flat fee per month.

*Percentage-based billing is illegal in some states, either in full or in part. Make sure you do your homework as to YOUR state’s law.

Sometimes the fees adjust up or down depending on collections or volume, sometimes not. 

Are there minimum fees? Implementation fees?

Are you paying additional costs, such as software, statement, or electronic transaction charges?

Be sure to ask which of the above RCM functions are (or are not) included. You can’t compare two different solutions on price unless they both offer all the same services.

And these are strictly the cost considerations…In Part 2 I will offer concrete guidance on things you need to contemplate before signing a contract with an outsourced biller or billing service. 

Even if you are outsourcing, you still have to monitor performance!  For instance, how will you know if your biller – whether contractor, in-house employee, or outside service – is collecting close to 100% of all revenue you have earned? You will have to identify a way to determine if money is being left on the table.

“Time vs. Money”

Is a spectrum, only a place to start evaluating your practice’s needs.  “In-house” and “outsource”both require time AND money

  • Doing your own billing: you have less time but make more money. 
  • Hiring an employee, virtual assistant, or a billing service typically allows you to achieve more time for yourself.
    (Or the ability to see more clients with that extra time.) But, there are more expenses that will reduce your income.

What’s Next?

Evaluate where you are in your private practice journey:

Where are you headed?
What does your ideal practice look like?
What is your ultimate goal for your practice?

These are personal questions that can’t be answered in a blog.  I highly recommend that you take the time to sit down and answer these questions realistically in order to make the best possible decision for your practice – your business!


When making your decision, consider what you want from your practice.

Where you are in your life and career will definitely play a role.

  • Just starting your practice? Mid-career? Headed toward retirement in a few years?
  • Do you have additional sources of income?
  • Number of client sessions per week do you want to do? 
  • How many hours per week do you need for documentation and clinical administration?
    (notes, treatment plan collaboration with other professionals, continuing education)
  • How many hours per week can you realistically devote to non-clinical administrative tasks?
    Consider: scheduling; billing/revenue cycle management; marketing; managing requests for new services; returning calls

What are you good at in terms of the billing world?

  • If you’ve done billing in the past or are doing it now, what do you struggle with? 
  • Can you learn to improve – and do you WANT to?
  • Based on the clinical hours you are going to work, what is your income likely to be?
    • Can you afford the services you want and still make an acceptable income?
    • If you cannot, then what is the best compromise until your income improves?
  • What’s your level of comfort with technology?

Finally, consider the ingredients I mentioned above that contribute to success in billing. 

  • There’s no shame if these don’t describe you – most of us didn’t earn clinical degrees with the goal of becoming a biller. (I’m an aberration!)
  • Keep in mind that what works for your colleagues, may not work for you.
  • It’s important to be realistic, whichever way you decide. 


In-house vs outsource isn’t so simple after all.  


I’ve barely scratched the surface – which is why there are several more parts to this blog on the way. I hope you’ll join me as I continue helping you decide what’s right for you.

Part 2: Outside biller: Evaluating services to find the best fit.

So, you’ve decided to hire an outside billing service. What now? How do you find the service that’s right for you? I’ll have lots of tips, so don’t miss Part 2.