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.