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Certified Professional Coder CPC Certification Exam


Everything You Need to Know About CPC Exam

Since the medical care industry continues to grow, you may be interested in finding a career in the field that suits your interests, abilities, and skill set. There is a wide range of jobs available, including medical billing and coding. These job positions are frequently fulfilled at a desk in a traditional office environment during regular business hours. 

This article describes what a certified professional coder is, recommends steps to prepare for the CPC exam, discusses the benefits of earning a CPC, and shares how you can make a CPC certification.


What is a Certified Professional Coder (CPC)?

A CPC is a person who has earned the designation by facing and passing a medical coding certification exam offered by the American Academy of Professional Coders (AAPC). Being a CPC means that you’ve proven your knowledge and understanding of medical coding so that you can work according to the standards of your industry.

CPCs use identifying codes to submit bills to insurance agencies for services a physician has provided to a patient. Certified medical coders should also have a minimum of two years of coding experience and complete a precise number of ongoing learning courses every two years.

Start Your Career With the CPC Exam

The Certified Professional Coder exam is the definitive step to achieving CPC certification. By passing the CPC exam and obtaining the right to attach the CPC abbreviation to your name, you become a medical care business expert identified for good proficiency of professional-fee medical coding.

Who Should Take the CPC Exam?

After you have trained to become a medical coder—or if you have considerable medical coding experience—you should take the chance to obtain certification by registering for the CPC test. Passing the CPC exam raises your incomes, possibly by more than $25,000 above annual salaries for employees without AAPC’s medical coding certification. And CPC salaries, averaging $57,201 in 2019, maintain a 9% increase every year. And also, the request for certified medical coders proceeds to increase, with a 23% growth in careers estimated by 2022.

What Is the CPC Exam?

The CPC exam consists of 150 multiple-choice questions. The exam takes five hours and 40 minutes to complete. There are two intervals in the middle of the exam, and the exam costs $300 to take.

The CPC exam exhaustively checks a coder’s knowledge of the entire coding process, from medical terms to code sets and far off. The CPC exam covers 24 subject areas, including physiology, radiology, and medicine.

Most questions present a coding structure to test the proper application of CPT procedure codes, HCPCS Level II supply codes, and ICD-10-CM diagnosis codes. However, the CPC exam is an open book examination. So during the test, you will reference approved coding books—the AMA’s CPT Professional Edition, ICD-10-CM, and HCPCS code manuals. 

You must identify a number of these as parts of the CPT code manual. Others, like Anatomy and Physiology, are parts of the coder’s standard skill set.

The exam questions are not divided or recognized by the topic they are related to. That is, questions on the CPC exam will test candidates on all of the 24 fields of medical coding, but they won’t directly say, “This is a human anatomy question.” instead, they’ll ask you about human anatomy or surgery, or anesthesia.

During the exam, you’ll face several tests cases concerned with the coding practice. These test case questions will present you with a condensed medical report and ask you to select the correct set of codes from the given answers.

For example, a test case question might read:

“Brian, a 48-year-old patient, visits the physician and presents symptoms including a sore throat, swollen lymph nodes, and a fever. After doing a rapid strep test, the physician verifies a diagnosis of streptococcal sore throat. The physician directs Amoxicillin as an antibiotic. Which of the following are the correct codes for this diagnosis, method, and direction?”

There are also general knowledge questions, such as “Which types of joints are synovial?” that don’t have a detailed test case. Candidates will have to trust their knowledge of code sets, medical terms, best practices, and the coding process in general to pass.

Candidates who earn a score of 70% or high (105 correct questions) will pass the CPC exam. If you fail your first test, you are allowed one free retake. 

CPC Exam is Now Available Through Online

AAPC recognizes the challenges that COVID-19 presents for CPC exam candidates, which is why it also offers the opportunity to take the CPC exam online.

CPC Online exam will include two parts given in Blackboard in two separate sessions and proctored by Examity. Candidates will schedule each part of the exam separately through the Examity platform, accessible through Blackboard, after obtaining or transferring the current exam paper. Exam scheduling instructions will email candidates when the CPC online exam receipt has applied to the candidate’s AAPC member account.

The candidate will connect with the proctor through Examity, accessible through Blackboard, to complete the confirmation and take each exam session. Exam results will post within 3-5 business days after the final exam session is complete.

Recommended Steps to Prepare for the CPC Exam

STEP 1- Online Medical Terminology & Online Anatomy Course

Deep knowledge of medical terminology and anatomy is needed for medical coding and tested in-depth during the CPC exam. These courses should be reviewed by anyone who needs to learn medical coding or for experienced coders who may be fragile in these areas.

STEP 2- Pathophysiology Course

A deep understanding of the disease process helps revenue cycle management stay ahead of the medical decision-making and quality measures curve. Therefore, this course should be considered by those who need to learn medical coding and billing or experienced coders who wish to strengthen their knowledge in this area.

STEP 3- CPC Preparation Course 

This course prepares students for a medical coding career in an outpatient physician’s office. Candidates preparing to sit for the CPC exam should have solid coding experience or have completed this course.

STEP 4 – Official CPC Certification Study Guide

The CPC study guide evaluates every section of the CPC exam and gives practical examples, sample questions, and techniques helpful for the exam. 

STEP 5 – CPC Online Practice Exams

Online practice exams are best for anyone who is getting the CPC exam. Following the content and difficulty level of the actual exam, these practice exams enable candidates to become more intimate with the format and time restrictions of the real exam. Although the exact length of the 150-question exam, the three practice exams can be picked up separately or as a complete bundle.

STEP 6 – CPC Certification Exam

The CPC Exam is an accurate, 150 multiple choice exam. Each exam comes with one free retake. Therefore, your chances of passing the CPC exam are highest when you’ve chosen to do your training through AAPC.

Benefits of earning a CPC

Here are just many of the benefits you can expect when you become a CPC.

  • Yearly earnings

As a medical coder, you may find that you earn a beneficial salary without a degree. The national average wage for coding specialists in the United States is $48,000 per year. However, your years of experience and location can influence your wages. For example, medical coding specialists in Tampa, Florida, average $58,300 per year, while those in Brentwood, Tennessee, earn $46,920 per year.

  • Job outlook

According to the U.S. Bureau of Labor Statistics (BLS), the job outlook for medical billers and coders is favorable. The agency projects an 8% change in employment through 2029, which is much faster than the average for all occupations. An optimistic job outlook typically correlates with job security.

  • AAPC opportunities

As a certified professional coder, you have the opportunity to visit events, training, and seminars hosted by the AAPC. Many of these events are free or come at a low cost, providing you with more awareness about the medical coding field and the chance to get to know other professionals from who you can learn.

  • Recognition

The CPC designation comes with more recognition in the medical field. It exposes patients and other medical care professionals that your understanding of medical coding is at an expert status and that you’re committed to your career. Employers value this certification because it considers a good skill set, and they usually reward their new hires with a higher salary and more earnings prospective. With the CPC certification posted on your cv, you may request more from a hiring manager too.

How to earn a CPC certification

Follow steps will help candidates to earn the CPC certification.

  1. Decide your optimal career path

You may be interested in a career in the medical field because of the job security of many positions. However, it’s essential to take the time to decide your conclusive career goals to make sure you enroll for the certifications, continuing learning courses, and higher education degrees that support your interests. Think about the essential characteristics of any job for you, whether that’s the responsibilities, annual salary, job outlook, or promotion opportunities. If medical coding is a perfect career for you, and if so, you can work to your CPC.

2. Earn your high school diploma

To sit for your CPC certification exam, you must have a high school diploma or similar, like your GED. The GED is a test that evaluates your understanding of high school subjects and is different to you have graduated from high school with your diploma. If you’re an adult who didn’t complete high school, then earning your GED is a feasible way to show the AAPC that you have the core capability to take the CPC exam.

Keep in mind that many coding experts have an associate degree from an authorized institution. Consider evaluating the career requirements from employers hiring coders to see if they mostly ask for an associate degree. If so, you may search for associate programs that support your career goals.

3. Gain professional coding experience

Without coding experience, you can still take the CPC exam and earn the CPC-A designation after passing the exam. You’ll then be able to continue working as a coder and later make the CPC appointment without the trainee classification after illustrating two years of hands-on experience. However, you may be able to gain experience before becoming certified, in which case you can take the CPC exam and detour the trainee classification.

4. Take continuing education courses.

The AAPC may exchange experience for education to drop the trainee classification from your CPC credentials. Therefore, consider enrolling for these classes that support your CPC certification so you can continue updated on medical coding.

5. Take the CPC exam

The AAPC issued the CPC exam, including radiology, surgical procedures, ICD-10, compliance, coding guidelines, and medicine. To qualify for the exam, you should be a member of the AAPC and pay your exam fee. 

You must plan to study for the AAPC CPC exam for at least two months. The more you know without having to use the books during the exam, the better. You will ensure that you complete all of the questions in the allocated time frame to perform the highest possible score.

After passing the CPC exam, you have to complete a few other steps for being officially certified by the AAPC. To achieve a CPC certification, you should become a member of the AAPC. Certification is also restricted to coders with two years of professional practice or those ready to complete a trainee program.

The CPC exam recommends for people who have already started their coding careers. However, that won’t prevent students from checking the primary points of this exam.

However, it would help if you kept in mind that none of the courses or the e-book will ultimately prepare you for the exam. Because the AAPC copyrights all of the test information and past tests, the best way to prepare for these exams is to take a course managed by AAPC. 


Medical Claims Management Solutions


Medical Claims Management Solutions Market Size and Forecast

A complete analysis of the Global Medical Claims Management Solutions market provides comprehensive information on the present market condition and reports and analyses on the industry’s potential size, volume, and trends over the forecast timeframe, 2021-2027.

Furthermore, this research provides a qualitative analysis of several segments in terms of general growth, development, potential, business strategies, processes, and so on. The research includes the revenue generated and developments made by various application segments, as well as the current trend gaining traction in the industry that raises awareness about the Medical Claims Management Solutions market.


Today, we will discuss Medical Claims Management Solutions which you should know how the market sizes vary in the near future. So here we go!

Medical Claims Management Solutions market size

The global medical billing outsourcing market is also presumed to achieve $24. 7 billion by 2027, growing at a 13.4% CAGR throughout the forecast timeframe. Outsourcing partners with record documentation of increased efficiency in claim operations, medical network management, medical document management, fraud monitoring, and other areas are likely to aid consumers in the marketplace.

The medical claims management market is being pushed by reasons such as an aging population, an increase in the prevalence of chronic diseases, a greater emphasis on medical quality services, and the introduction of innovative treatments and technology.

Limitations such as rising worries about patient data safety and security, privacy violations and loss of privacy, and a shortage of trained IT experts in healthcare are stifling the growth of the medical claims management systems market. Nevertheless, according to American Medical Association’s (AMA) 2011 National Health Insurer Report Card, reducing claims mistakes may save approximately $17 billion per year (on ordinary).

The COVID-19 impact on the Medical Claims Management Solutions market

The report discusses the impact of the Coronavirus. COVID-19: Since the emergence of the COVID-19 virus in December 2019, the epidemic has spread to almost every country in the region, prompting the World Health Organization to declare it a public health emergency. The global effects of the coronavirus illness 2019 (COVID-19) are already being seen, and they will have a substantial influence on the Claims Management Solutions market in 2020.

The COVID-19 outbreak has emphasized the importance of proactive action and the creation of a strong, scalable, collaborative, and responsive digital healthcare infrastructure. As a result, numerous firms are pursuing different strategies, such as digitalization and outsourcing of all non-core aspects of their operations, such as billing and accounts, in order to promote market development.

The rapid adoption of digital billing is immediately proportionate to the expansion of the medical billing outsourcing business.

This situation is changing, and the offer of insurance analytics solutions has increased as a result of increased adoption of modern technologies and growing competition between many insurance firms in the coming years.

Outlook on Components

The market is divided into Tools and Services based on the component. During the forecast timeframe, the equipment segment is expected to have the largest market position. Insurance analytics tools are widely used by a variety of end-users, including third-party admin staff, insurance firms, agents, and brokers, to gain a competitive advantage over their competitors by leveraging information as a strategic asset.

Outlook of Application

The industry is divided into four applications:

  • risk management,
  • customer management and personalization,
  • claim management,
  • Process optimization, and many others.

Over through the forecast timeframe, the risk management segment would gain a sizable market share. Insurance providers are widely utilizing analytics capabilities to learn about risks involved and implementing appropriate methods to decrease losses, or at the very least screen, prevent, and determine the cost of risks associated in the underwriting process.

Outlook of Application

The market can be divided sections depending on the application: Large Enterprises and Small and Medium Enterprises. Some many large-scale enterprises are attempting to use insurance analytics to improve customer allegiance while lowering total capital costs.

Furthermore, insurance analytics tools allow large enterprises to comply with constantly changing government standards and regulations constituted by HIPAA, the Federal Government, and the Payment Card Industry Data Security Standard, which is expected to accelerate future growth.

Outlook of end-user

The market is divided into three segments based on end user: insurance providers, governmental organizations, and third-party executives, brokers, and consultancies. Insurance companies require a large amount of data that can be conveniently collected and analyzed using health coverage analytics.

Insurers can collect and analyze structured data on policyholders as well as unstructured data from public platforms such as social media. Large enterprises can also use the insurance analytics tool to create simple and transparent products.

Medical claims management solutions market research report

The Medical Claims Management Solutions market study combines the prospective stream of the Medical Claims Management Solutions industry with an examination of existing market trends and growth strategies. The Medical Claims Management Solutions market research outlines the industry breadth with key manufacturers and its categories from around the world.

The study includes basic and detailed information on industry influencing elements and upgrades, target business areas and resources, limitations, and advancements. The worldwide Medical Claims Management Solutions market research also provides a detailed study of the market participants’ SWOT analysis, as well as assesses the size and share of the global industry.

The market research study gives a general review of the industry, covering definition, categories, applications, and the industry hierarchy structure. Global Medical Claims Management Solutions market research is given for worldwide markets, covering growth trends, competitive landscape analysis, and major development status.

Industrial methods and cost structures are also examined, as are policy reforms and goals. This report also includes figures for import/export consumption, supply and demand, cost, price, income, and profit growth.

Before purchasing this report, please inquire at –

The following are the major topics discussed in the report:

  • Size of the Global Medical Claims Management Solutions Market
  • Manufacturers compete in the market.
  • Economic Influence on the Growth Rate of the Medical Claims Management Solutions Market
  • Market segmentation based on type and application
  • Analysis of the Production, Revenue (Value), Price, and Medical Claims Management Solutions Market Trends
  • Cost analysis, industrial chain, raw material sourcing strategy, and downstream buyers are all important considerations.
  • Production and revenue (value) by geographic segmentation
  • Understanding Marketing Strategy, Distributors, and Traders
  • Forecast Analysis of the Global Medical Claims Management Solutions Market
  • Factors Influencing Market Research

The Medical Claims Management Solutions market is segmented primarily as,

  •   On-premise
  •   Cloud-based

The Medical Claims Management Solutions market from 2020 to 2027 is segmented by application and includes:

  •  Property insurance
  •  Life insurance
  •  Health-care coverage

As follows is a market segment: Geographically

  • Asia-Pacific region [China, Southeast Asia, India, Japan, Korea, and Western Asia]
  • Europe (Germany, the United Kingdom, France, Italy, Russia, Spain, the Netherlands, Turkey, and Switzerland)
  • North America consists of the United States, Canada, and Mexico.
  • The Middle East and Africa [GCC, North Africa, and South Africa]
  • Brazil, Argentina, Columbia, Chile, and Peru are all located in South America.

The report also examines the renowned companies’ financial status, which contains gross profit, generating revenue, the volume of sales, product sales, cost of manufacturing, independent rate of growth, and other profitability statements.

Methodology in Research

The information gathered comes from a variety of services, respectively primary and secondary. The information includes a description of the different aspects that either affects the Medical Claims Management Solutions market. The data has undergone a SWOT analysis, which can be used to correctly estimate the different factors used to evaluate a company’s growth.

The report includes an extensive analysis of the various opportunities and threats that can be utilized, as well as a discussion of a company’s strengths and limitations.


The report on the global Medical Claims Management Solutions market is an in-depth examination of a number of factors that are pervasive in the Medical Claims Management Solutions market. An industrial overview of the global market is offered, as well as the demand growth anticipated with the retail items.

The report identifies and mentions major companies with a large market share, as well as the various products they sell on the global market.

AdvancedMD Medical Software Features, Pricing & Overview

AdvancedMD medical software features, pricing & overview

AdvancedMD Medical Software Features, Pricing & Overview

It can be a hassle for your medical staff to manage multiple levels of claims at once. Given the breadth of features in the software and the high level of experience, it is best suited for extensive bill rights management. The fact that suppliers are spread across several locations is another reason AdvancedMD is suitable for large claims. In addition, the system is more flexible, and the software can adapt to the customer workflow.

AdvancedMD is

AdvancedMD is a cloud-based medical software with features that can be modified to fit any workflow. This medical software has a unique interface that helps the convenience of the suppliers. This medical software is designed to simplify billing transactions with several benefits and features such as patient data entry, bill rights management, message automation, and having a wide range of tool platforms. Platforms can be customized to your needs, and you will be able to perform all tasks with quality through a more organized patient portal.

Why AdvancedMD has the highest customer demand?

We can introduce the medical billing software industry as the most profitable and emerging industry in the global industrial market of the 21st century. Of these, more than 75 percent of medical billholders are in high demand for advanced MD medical software. The main reason for the market is the unique benefits of the software.

• Being a more flexible system

Many features of the AdvancedMD platform are designed to be better organized according to customer needs. In addition, this medical software has a more up-to-date user interface. What is your preference? Advanced MD has several compatible features. Sometimes a new user may have a number of these features and be a little apprehensive about activating them at once. But with a good guide, you might find what you need.

Advanced MD also can integrate all your workflows through the software system. It is much easier to integrate with other pharmacies, multi-insurance departments, and laboratories. This medical software is designed to handle medical information accurately and for the patient to update their information. Advanced MD offers features and tools as add-ons. It allows you to select the tools you need and fail to make a payment for unused ones.

• Ease of medical review

AdvancedMD Medical Software makes filling in reviews more accessible and more efficient. This benefit allows patients to access opportunities to review physicians online and to review information. AdvancedMD also enables you to accurately track the number of reviews users have and see the effectiveness of the training.

• Increase in income

AdvancedMD has several features and tools that make it easier for the doctor or user to administer. In it, the user has more time to focus on the patient. Plus, you’ll be getting rid of clutter you don’t need. Medical software can perform most of the tasks of staff without paperwork. Providing a more reliable service to patients will increase the number of patients coming to you per day and revenue.

• Excellent patient relationships

AdvancedMD Medical Software has an organized patient portal. Through it, the patient can quickly deal with the doctor. AdvancedMD is also ready to accept applications for iPhones and iPad to make it easier for the patient to communicate with the doctor at any time.

AdvancedMD Medical Software Features, Pricing & Overview
Photo Credit- advancedmd. com

Key Features

  • Payment of bills

AdvancedMD medical software is compliant with the ICD-10 and CPT codes. The particular billing module here provides special RCM equipment. All fees are entered immediately after the doctor issues the report after any patient appointment into the Advanced MD medical software billing. The specialty of the software is that AdvancedMD is committed to collaborating with clearing centers such as Wester and TriSestro.

It contains ICD-10 code, which allows you to find the code more quickly and efficiently. In addition, advancedMD billing software provides a digital set of all electronic transmission instructions, making it easy for members to submit reviews. Through this billing service, a certified and accessible group will have the opportunity to access copyright-related software.

In addition, the Advance MD Medical Billing Software enables you to manage the claims better or revoked claims of insurance companies or patients. You also have the power to control it if you have problems resolving it two or three times. Finally, the software is integrated with the Credit Card Processor to capture patient arrears, making it easier for you to obtain credit and debit at each patient appointment.

  • Schedule appointments

The Advanced MD medical billing software schedule board is more intelligent. It has a drag-and-drop interface. Through it, you get appointment scheduling, automatic calendar, customizable filters, etc. It makes it easier to update and register patient records related to a new appointment. In addition, after confirming patient appointments through this medical software, you can quickly check the relevant insurance qualifications.

A unique feature of Advance MD is the documentation of appointment information. It also has an assignment tool that makes it easier to manage waiting lists when rescheduling appointments that have been canceled or rejected. In addition, with Advanced MD Medical Software, you can make patient payments, appointment reminders, and re-appointments without any hassle.

  • Patient portal

Patients now have easy access to medical appointments from anywhere in the world. For that, the patient portal at AdvancedMD is the most suitable. It allows patients to quickly find their lab results, get prescriptions, and pay their medical bills. Through the patient portal, each patient also has the opportunity to communicate directly and more securely with the doctor. Physicians can use the Advanced MD Patient Portal for anything from prescription updates to warnings.

  • Recording.

AdvancedMD, The complete billing system of medical billing software, is called Advanced Insight. Here is a financial dashboard that records filters. It is easy for you to handle to display key performance indicators. This system efficiently filters each record by chronological order and gets only the information you need. Advanced MD Medical Software can help you with various tasks, such as generating recurring article reports and data graphs more easily.

  • E – Recommendations.

You can quickly and efficiently perform the electronic recommendations of AdvancedMD. You will contact pharmacies across the United States more successfully through e-Recommendations to get things like prescriptions, prescriptions, etc. In addition, AdvancedMD Medical Software, Advanced EPCS maintains a complete DEA history. Therefore, you can easily access an account of medicine from anywhere.

  • Dashboard.

The dashboard of the AdvancedMD is more intelligent. This one is designed to adapt to any situation, such as health analysis reports, laboratory results, prescriptions, and more. Here you can use the custom “donut filter.” The dashboard also shows you several functions, such as listing appointments, automatic reminders, and checking security messages. The doctor-oriented dashboard in the medical software allows you to view all staff referrals in one place. In addition, doctors will be able to send messages to their staff through the Intermail Center.

AdvancedMD Medical Software Features, Pricing & Overview
Photo Credit-

Communication with the patient.

There are several tools in the Advanced MD medical software to maintain patient communication better. For example, you can use the software to send patient-related messages via email or SMS, group patients’ lists, and send accurate messages. The Kiosk mobile app also speeds up patient research processes and automates information.


You will only be charged a one-time installation fee for activating the Advanced MD Medical software. That value is about $ 5,000. This charge includes more than 20 hours of training, including custom configurations and online training.

It also consists of an account manager to make it easier for you to activate the software and monitor it for a few more days. Once you have the insurance credentials, the Advanced MD medical software activation time and training period are 8 to 11 weeks.


AdvancedMD pricing models are slightly different than other medical office software. It also has an appointment-based charge. That is, payment must be made at the time of meeting one patient. That advantage is significant for small medical training. For example, one customer pays $ 499 per month without EMR. A system with EMR costs $ 729 per month. For an appointment-based feature, you pay $ 2.18 per appointment.

Prices for EMR medical software systems remain the same. AdvancedMD’s EMR system is a bit more expensive, but it’s the only medical software that offers a pricing model for appointments. AdvancedMD is costly because it has a few extra add-ons. In addition, there are several automated systems.

Customer support.

AdvancedMD Medical Software Company has the opportunity to address and resolve your issues through technology remotely. There is a permanent support agent here for that. You can contact a supporter over the phone or live webchat. Phones are open from Monday to Friday during working hours. In addition, customers can get software training through many opportunities like videos, guides, webinars. It should also be noted that there is no email support.

AdvancedMD Limitations

  • Basic setup and learning of Advanced MD medical software can be a bit difficult.
  • An inventory module in the software is not provided for immunization.
  • There are no features for tracking travel numbers in the patient report chart and patient data.
  • Scanning PDF documents can be a bit difficult.
  • Advanced MD is difficult to match with android devices.


1. What are the supported platforms for AdvancedMD?

windows 7, windows 8, Windows XP, Windows 10, web browser (OS agnostic)

2. Who is eligible to use Advanced MD software?

Medical billing companies, doctors, small business owners, clinicians, mental clinical

3. Is there an app for Advanced MD?

You can use the mobile application of the EHR system of Advanced MD.

4. Who is the AdvancedMD Owner?

AdvancedMD is owned by Marling, a global leading investment firm with $ 6.7 billion in assets. Introduced in 1999, they introduced AdvancedMD as the first cloud solution in the medical software industry.

5. Who is the Advanced MD CEO?

The CEO of Advanced MD is Raul Villar. The production director is Matt Barron.

10 steps in medical billing process


What are the ten steps in the medical billing process?

The medical billing process is a set of operations carried out by billing specialists to guarantee that medical practitioners get compensated for their services. In other words, medical billing is a procedure used by health care organizations and insurance firms to handle medical treatment and service expenses. Based on the conditions, it may take only a few days to finish, or it may take several weeks or months. While each medical office’s procedure may vary somewhat, below is a broad overview of a medical billing system.

Medical billing services are divided into three stages: check-in, claim, and post-claim. However, this procedure is growing more complex as players become more cautious and meticulous in verifying the integrity and avoiding fraudulent actions. As a result, before beginning the medical billing process, it is critical to understand each stage in detail properly.


Every business has its method or process that helps it to be profitable. Similarly, medical billing firms adhere to a distinct procedure to remain ethical and commercial in the marketplace. Therefore, medical billing services include Revenue Cycle Management as an essential component. Revenue Cycle Management provides a system that disputes every denials and posts payment on schedule.

So today, we will discuss ten steps in the medical billing process that you must have better understand before choosing medical billing.

Implementing a proper medical billing process may expedite the procedure, decrease complexity, and result in speedier claim submission and reimbursement. Here are ten measures to make the medical billing procedure more accessible and less time-consuming for your organization.

Steps in the medical billing process :

  1.     Patient registration
  2.     Insurance verification
  3.     Encounter
  4.     Medical transcription
  5.     Medical coding
  6.     Charge entry
  7.     Charge transmission
  8.     AR calling
  9.     Denial management
  10.     Payment posting

Let us discuss them in detail.

1. Patient registration

Patient registration is the first step in the medical billing and coding process. Before the treatment, the front desk personnel collects the essential data and information from the patient to schedule an appointment with the doctor. Then, medical billing firms use the patient’s medical information to establish the claim as quickly as the patient registered with the practitioner.

Furthermore, experienced medical billers check that the information supplied in the initial stage is correct. Check-in and check-out are essential components of the patient registration procedure. To be more specific, the front desk personnel passes out a form to the patient to gather information.

Even though the medical billing staff has the information, they validate it with the patient’s identification or driver’s license to ensure their identity. Then, when the patient checks out (following the visit), the information and services given are collected into a superbill. From here, the entire medical billing and coding procedure begins.

Patient registration step:

  • Data and information, including insurance validation, are detailed to file a claim for healthcare services given.
  •   To enable faultless invoicing, the RCM organization maintains a firm grasp on the patient’s data.
  • The procedure described above is solely applicable to the new appointment. The information from previous meetings will already be preserved.
  •   It allows medical billers to double-check the information given before submitting a claim.

2. Insurance verification

In this phase, the patient’s insurance is entirely verified by outsourcing medical billing services. The healthcare plan is extensively examined to ensure that eligibility and policy compliance are met. Following the verification process, billing specialists discuss the patient’s responsibilities, including deductibles, copayments, and out-of-pocket expenditures.

Pre-authorization from insurance providers is required in some situations before services are given. It happens in this phase as well. To preserve and validate information, many medical billing systems employ digital methods.

The biller verifies insurance coverage to eliminate any questions about what the insurance provider will cover. If such insurance does not cover the services, the biller informs the patients that they will be responsible for the whole amount.

3. Encounter

Terminology for a meeting between a patient and a provider in which the patient describes the problem and the provider analyzes the patient’s condition to make a decision that will aid in the patient’s recovery. It is a session that has been captured using audio or video technologies. Claims may be perfectly prepared if the information is correctly gathered and the session is carefully recorded.

When a patient meets with a healthcare professional, the specifics of the ailment and the treatment provided are recorded, whether audio or video. These details may be documented in front of the patient or after the meeting. It clarifies the illness as well as the medications given by the healthcare practitioner. Then, they send the record to the RCM firm. 

4. Medical transcription

A medical script is created by transferring recorded audio or video. The hand includes the whole state of the health record. Medical transcription is the process of transcribing voice-recorded or video-recorded medical reports by healthcare practitioners. It is critical to keep a prepared and modified file on hand. Ascertain that the transcription contains no misleading or incorrect data, which might affect the patient’s health.

Specialists listen to the recorded session and enter information into a medical script, then used to finalize and manage the patient’s health records. This must be an error-free procedure since updated records are utilized in future follow-ups, providers look to these documents to offer treatment, and any inaccurate information curtails a patient’s medical history, resulting in improper decision making. Perhaps not that, but the paper is also utilized for invoicing reasons. Thus any incorrect information would impact the claim as well.

5. Medical coding

According to the American Medical Association’s guidelines, a group of professionals reads the document created from the recording and converts necessary details such as where the service was provided, the reason for the visit, the measures taken by the provider to solve the current condition, and so on into the numeric or alphanumeric-codes. It is necessary for two reasons: initially, it is simple to comprehend, and later, it is a legal necessity.

Also, in simple terms, medical coding is,

• Medical coding is the process of converting a patient’s condition, medical treatments, and medical prescriptions into medical codes.
• For a time-saving and straightforward operation, the transcript information is transformed into medical codes.
• Reading the patient’s entire medical history takes more time. As a result, it is programmed into codes.
• Medical coding is only done by the medical staff. Therefore, they should be knowledgeable and competent in certain areas of medical coding.
• Coders depend on patient condition and service given to the patient to convert the medical record into a medical code.

6. Charge entry

Charge entry is the next step in the medical billing process. The expense expended to deliver the service or the most significant collectible amount is included in the costs coded by the coding crew; it is one of the stages necessary to produce the claim form that needs to be submitted to the insurance company; without the stated value, no money can be collected. Again, specialists monitor and control to ensure that the correct discount is applied, as an error may lower the claim payout.

7. Charge transmission

After successfully setting up the claim by entering patient information, provider information, services given, and so on, the claim has become ready for submission for payment. Medical billing claims are transmitted in a safe and encrypted manner.

Transmission errors are classified into three types:
• Scrubbing- Required fields must be filled out correctly. Otherwise, the program would reject the claim.

• EDI rejection- Incorrect entries in the patient’s record will result in claim rejection via EDI.

• Payer rejections- Claims are rejected based on insurance restrictions and payer data.

Only once these three stages are completed denials or payments executed.

8. AR calling

These experts manage insurance claims that have been refused and are not being paid, even after remedial actions have been made to make a claim payment. They focus on thorough follow-up with health insurers, gathering facts about the rejection, researching, and organizing to keep revenues flowing.

They communicate accurate information with teams such as Insurance Verification, Coding, and Charge Posting for future claims. They are also in charge of managing and preserving inbound and outbound insurance communications.

9. Denial management

Insurance companies will only process claims that are received within the time frame stated. When a claim is accepted, it goes through a procedure called adjudication. After applying specific checks to the lawsuit, they determine whether to pay or deny it; occasionally, they spend part of the claim while rejecting the remainder of the costs.

Professionals that handle denials prioritize the claim based on the time remaining for submission to insurance and the amount remaining to be recovered, guaranteeing optimum revenue production. In addition, they track denials to identify patterns of denial and implement remedial actions to ensure that future claims are not refused.

10. Payment posting

Payment posting is the final step in the medical billing process, which allows the team to stay up to speed on the payment status. Patients are given EOBs (Explanation of Benefits) and ERAs (Electronic Remittance Advice). The Payment Posting team additionally verifies that the payment received is correct.

The posting team captures denials and payments using EOB or communication receivable from insurance carriers. The posting team must match the significant payment liabilities with the cheque amount. The patient and insurance revenue will be computed using the payment deposited to the practice accounts.

These ten steps take the medical billing process towards the next level of Revenue Cycle Management by ensuring consistent revenue increase and access to a massive number of medical claims with no mistakes and fewer rejections.

What is Revenue Cycle Management?


What is Revenue Cycle Management (RCM) in medical billing?

Revenue Cycle Management is critical to the profitability of any healthcare organization. Medical billing is one of the components of Revenue Cycle Management. However, RCM extends beyond payment posting. Medical practitioners use RCM to evaluate, track, and adequately manage the progress of patient claims on the receivable accounts.

The medical sector’s backbone is Revenue Cycle Management (RCM). It oversees the providers’ money and maintains them running regularly. There are numerous organizations engaged in the process to ensure its success. The importance of medical billing services and front-desk personnel in the United States cannot be overstated.


If you are interested in the medical billing sector, you must be familiar with RCM. Today we are going to discuss RCM (Revenue Cycle Management), which is most important for medical billing. So you have not any sound knowledge or have not been heard before, do not worry. Let us discuss all relevant information from the beginning.

What is Revenue Cycle Management?

Revenue Cycle Management (RCM) is the process of finding, gathering, and administering revenue from patients depending on the services given by the organization. An effective RCM process is important for a healthcare practice’s financial sustainability. And in order to keep providing excellent care to its patients.

The shift toward value-based compensation and more holistic patient care has compelled healthcare professionals to reconsider their approach to revenue cycle management. Improper billing processes can lead to financial losses and jeopardize the capacity to provide quality treatment.

RCM integrates healthcare’s medical and administrative aspects by combining administrative data, like a patient’s name, insurance provider, and other private information, with the treatment they get and their health records. With the treatments they get and their health records.

Communication with health insurance companies is an important aspect of RCM. When a patient makes an appointment, the practitioner’s office or facility personnel usually double-checks the patient’s stated insurance coverage before the visit. A healthcare practitioner or coder classifies the nature of the treatment using ICD-10 codes. 

After an insured patient receives treatment for a particular illness and pays any appropriate copayment. The hospital or care provider then submits the service brief, complete with ICD and Current Procedural Technology codes, to the client’s insurance company to determine what percentage of the treatment will be reimbursed by insurance, with the patient billed for the balance.

The Revenue Cycle 

Revenue Cycle Management entails more information and procedures than what we deal with in billing services. RCM is concerned with the administration of different financial transactions that arise as a result of medical interactions. The interactions take place between patients and medical suppliers, institutions, or health care providers.

Transactions are including:

  • Billing
  • Coding
  • Collections
  • Compliance
  • Data Analytics
  • Management Duties

So you can now understand, RCM is a complicated process. It must be. Your first concern should be to keep the lights on and pay your employees. Otherwise, you will be unable to serve patients.

According to the Healthcare Financial Administration Association, the revenue cycle encompasses all medical and administrative tasks that assist in capturing, administering, and collecting patient service revenue (HFMA).

The revenue cycle comprised of the following steps:

  • Charge capture: Charge capture is the process of converting medical services into billable costs.
  • Claim submission: Claim submission is the process of submitting claims for billable expenses to insurance companies.
  • Coding: coding diagnosis and procedures correctly.
  • Patient collections: Patient collections entail calculating and collecting patient balances.
  • Pre-registration: Pre-registration is the process of gathering pre-registration information, like insurance coverage, before a patient arrives for inpatient or outpatient operations.
  • Registration: Registration entails gathering more patient information during registration in order to create a medical record number and fulfill numerous regulatory, financial, and clinical criteria.
  • Remittance processing: The application or rejection of funds via remittance processing.
  • Third-party follow-up: Collecting reimbursements from third-party insurers is referred to as third-party follow-up.
  • Medical service review: Examining the need for medical care 

Difficulties in managing the Revenue Cycle

The Revenue Cycle commences when the patient schedules an appointment and concludes when money is collected successfully. However, several procedures must be done properly and swiftly in order to assure prompt payment. Human error owing to coding complexity, misunderstanding, medical billing errors due to duplicate data, and incomplete information or spelling mistakes all have the potential to result in revenue loss.

Obtaining timely compensation might be complex due to constantly changing healthcare regulations and reimbursement methods. This can also place additional demands on employee time and frequently necessitates using suitable software technologies to conduct essential reports. Healthcare practitioners frequently deal with minimal resources. To achieve RCM success, providers must often focus on increasing organizational productivity.

The benefits of a Revenue Cycle Management system

Many healthcare providers decide to invest in Revenue Cycle Management (RCM) software, generally a Practice Management product. However, some providers may prefer to outsource RCM in order to assure a complete and correct understanding of ICD-10 codes.

RCM software is typically suitable, although it can also interface with Electronic Health Records (EHR). Integrating with other EHR systems can help store and maintain patient billing information and effectively shorten the time while seeing the patient, billing, and payment.

An RCM system may be able to help with the shift from fee-for-service to value-based compensation by providing a more comprehensive view of the patient demographics. Other advantages of an RCM system may include:

  • Saving time by automating tasks like appointment and payment reminders and contacting insurance about claim denials.
  • Providing information on why a claim was refused
  • Include mistake detection to aid in the correction and monitoring of underpaid claims.
  • Possibilities for reviewing revenue shortages
  • Issuing staff urges to input information in order to save money on claim revisions and get insight into why claims may be refused
  • Ensure correct compensation for medicare patients
  • Identifying a patient’s financial status and payment requirements

Factors that may affect Revenue Cycle Management

The supplier has limited influence over the payment resulting from the claim review and rejection procedure. Long wait times for billing and claims to be handled for provider payments may occur from claims denied owing to insurance verification difficulties and increased efforts to prevent healthcare frauds and misuse.

However, there are specific internal issues over which the supplier seems to have some control. Providers may enhance their Revenue Cycle Management by focusing on productivity, patient volume, and collecting payments for services. 

Among the issues that might obstruct the Revenue Cycle Management process are:

  • Patient payments collection

The patient’s contribution to healthcare expenditures is increasing. Therefore, when patient payments are collected before or during their service, the danger of lack of payment is totally eliminated. However, this is frequently a complicated process because many people cannot afford the large deductibles and are ignorant of their financial responsibilities.

Patient pre-registration is critical for obtaining the correct information about a patient’s history and insurance details ahead of time in order to prevent claim denials. In addition, this allows for the payment process to be front-loaded by obtaining information regarding insurance coverage, supplementary insurance, the patient’s maximum permitted visits, and assessing the patient’s financial responsibility.

  •  Issues on eligibility

Communication with medical insurance companies is essential. Failure to manage the insurance claims after submission can result in pending, rejected, or denied claims, as well as claims that were never received. Monitoring claims to discover where problems arise, like difficulties with certain procedures or codes, can assist raise awareness and minimize recurrences.

  • Insufficient digital workflow

Without such capacity to simplify the digital workflow, inaccurate data and future revenue cycle difficulties might occur. Creating effective supporting healthcare IT architecture can help with Revenue Cycle Management and the capacity to process required reports. Implementing an electronic workflow can also aid in the smooth coordination of front and back-office communication and the elimination of missing paper paperwork.

  •  Administrative processes are fragmented

The front and back ends of the office sometimes have opposing priorities. Claim denials can occur if the information is not given. Effective communication about coverage status at patient registration can help with insurer coordination, claims reimbursement, and payment collecting.

Priority should be given to front-end administrative activities to expedite claims and help underprivileged patients understand their coverage choices through insurance marketplaces. Revalidating patient insurance details are frequently missed on future visits, resulting in eligibility denials.

Management of the Revenue Cycle Management process

Understanding and enhancing an organization’s core operations systems can enable the provider to begin managing the RCM process instead of allowing claims to influence the provider’s financial sustainability. In addition, focusing on early identification of difficulties with pre-registration may aid in identifying eligibility concerns and averting first claim denial, while using RCM software may assist in ensuring timely payment.


HIPAA Compliant Accounting Software Market May See A Big Move


HIPAA Compliant Accounting Software Market 

What is HIPAA?

The United States passed legislation in 1996 to ensure all individuals’ medical data privacy and safeguarding. In the middle of that year, President Bill Clinton signed the Health Insurance Portability and Accountability Act (HIPAA) and included five main sections:

HIPAA section I

The first section gives protection for maintaining medical insurance coverage for any person changing or losing their job. It also forbids group plans from refusing people with prior conditions and diseases to cover and bars them from setting lifetime coverage limits.

HIPAA section II

Section II expresses that the US Department of Health and Human Services should initiate a national standard for processing electronic medical care. In addition, all medical care organizations should also implement security measures for medical data access and respect privacy legislation.

HIPAA section III

section III of the HIPAA act gives guidelines for tax provisions and health care.

HIPAA section IV

The fourth section says the medical insurance reform in greater detail. It expresses the facilities for those who look for continued coverage under the act and the laws respecting former conditions.

HIPAA section V

Under section V, services are for people who give up their US citizenship and affect their income tax. It also states rules for company-owned life insurance plans.

For anyone working in medical care information technology, HIPAA compliance means attaching to the requirements of section II, known as the provisions of Administrative Simplification.


Compliance Requirements of section II:

  • Companies should submit and process claims following a standardized electronic data interchange (EDI) protocol.
  • The Standards for Privacy of Individually recognizable medical details, or Privacy Rule, initiates nationwide standards for the protection of patient medical information.
  • The Security Standards is about the safety of Electronic Protected medical details, or Security Rule sets the standard for data security of patient records.
  • The HIPAA Enforcement Rule states guidelines for investigating compliance violations of HIPAA.

The HIPAA Omnibus Rule executes alterations to HIPAA concerning any companion of a covered object. In addition, it increases compliance violation penalties to a maximum of $1.6 million per incident.

A HIPAA negligence can be critical financial trouble for a medical care company. Under Omnibus, the HIPAA Breach Notification Rules declare all business partners must report all patients of the violation and show the cost of such notifications. The people are then audited and pay fines. Lastly, providers could face criminal prosecution for their transgressions.

HIPAA compliance training programs decrease an organization’s danger of administrative action. There is no official compliance certification for HIPAA, but many organizations offer certificates to prove completed compliance training. In addition, the US Office for Civil Rights (OCR) provides six programs teaching compliance rules, and some numerous private groups and consultants can hire as well.

HIPAA Compliance

Regulations such as HIPAA require clearness first and principle. Any activity turn around regulated data systems may audit. Therefore, there must be checks and balances and procedures in place within the organizational arrangement to ensure that electronically protected health information (EPHI) is:

  • Not reachable to anyone except those who have a verified business necessity for it
  • Carefully monitored during such access
  • Encrypted while in storage and during the transfer on any unprotected network, and only move to authorized locations

The above requirements consider four primary practices central to HIPAA compliance, as described below. Within these are many other aspects crucial to data security, such as data loss protection, secure backup of data, process and technical controls, network configuration, and the human element necessary to work efficiently.

Identity Management and Access Controls

Access controls are a great example of the necessity for technology within the data flow. Custodians, supervisors, and owners should be involved in who can access secure EPHI. Unfortunately, there is no standard for technology in this.

However, hiring identity and access management tools is brilliant for anybody wishing to follow HIPAA. It would be nearly impossible to control access and related records of requests, approvals, and denials without such technology. In addition, technological systems can more help by automating the critical account privilege recertification.

System and Environment Configuration Controls

Any system that stores protected data should configure under stringent guidelines. It is imperative to know the state of critical systems at any given time within the regulated environment; simple monitoring is not sufficient when protecting data of this magnitude.

Each system should be separate, configured solely for its unique purpose, monitored for vulnerability, and ensure that all software versions are up-to-date and administered securely.


It is crucial while controlling sensible details to know who has access at every time. Under HIPAA, it is not only the data that monitoring but the access to said data. Any application or technology that allows access to information must have a means of logging access, which should monitor strictly.

Information Flow Control and Encryption

Data must be protected where it is stored. But in this age of technology, information never sits long in one place. Therefore, the fourth and final compliance element should secure details at all times. It must always be encoded through transfer and may only move to secure previously approved locations.

HIPAA compliance is not an easy job to achieve. As a combination, it can appear pretty complex and practically indistinct. But when broken down into primary segments, HIPAA compliance is possible for any company wishing to be go-ahead in its endeavors. 

First, figure out who will be in charge of compliance within the organization, and set the policies necessary to comply. Next, get the technology required to maintain access controls and data security. Finally, have those responsible trained through a compliance class? 

You can untwist the rough patches and adjust policies as necessary as you go, but the first steps must be identifying what needs to be protected, who will do so, and how they will do it!

HIPAA Compliant Accounting Software Market Overview:

HIPAA Compliant Accounting Software research study describes the market size of different segments and countries by historical years and determines the values for the next six years. Qualitative and quantitative elements of HIPAA Compliant Accounting Software industry include market share and market size that respects each country concerned in the competitive marketplace.

Further, the study also feeds to and provides in-depth statistics about the crucial elements of HIPAA Compliant Accounting Software which includes drivers & restraining factors that help estimate the future growth outlook of the market. 

The segments and sub-section of the HIPAA Compliant Accounting Software market are below:

  • The study segmented by following Product/Service Types: On-premises & Cloud-based
  • Primary applications/end-users industry are as follows: SMEs & Large Enterprises.

Some of the key members in the market are Sage Intacct, Kareo Billing, Medisoft, Cliniko, Better Clinics, NetSuite, NueMD, Sage X3, Xero, and CollaborateMD.

HIPAA-Compliant Healthcare Cloud Accounting Software

The exclusive medical care accounting software initiate by the AICPA and Healthcare Financial Management Association Peer Reviewed.

HIPAA has protected patients’ private medical records. As a result, a healthcare practice must adhere to HIPAA regulations, and beyond that, the software used to manage your practice must also be HIPAA-compliant. As a result, it can be frustrating for healthcare providers who find a solution, only to discover it needs all-important compliance features. 

While some HIPAA-compliant software has been built especially for the medical care industry, users may dislike these products’ awkward interfaces or poor capabilities. Thankfully, there is a best-in-class cloud accounting software with an excellent feature set for the healthcare industry, including HIPAA compliance—Sage Intacct.

About Sage Intacct

Why is Sage Intacct a best-in-class cloud accounting software? Because Sage Intacct offers broad functionality in particular sections of accounting and financial management. Users with an internet connection can access data from this software at any time and from any device. As the best solution, Sage Intacct also claims an open API, integrating with many other best solutions.

Avertium reviewed Sage Intacct under its HIPAA Compliance Program (HCP) and granted the software a “Compliant” status. In September 2020, Sage Intacct became the first and only cloud financial management system to receive a Peer Reviewed designation from the Healthcare Financial Management Association (HFMA). 

Sage Intacct’s compliance features and its multi-currency and multi-entity capabilities make it a compliant yet flexible system. 

Solutions like QuickBooks Enterprise and Oracle NetSuite often consider alongside Sage Intacct. However, while these offer broad functionality, they lack the HIPAA-compliant features that make Sage Intacct viable for healthcare organizations.

Sage Intacct’s HIPAA-Compliant Features

Sage Intacct’s features attach to HIPAA guidelines so that medical care companies can benefit from a proficient financial management system while still maintaining the administrative agreement. 

Advanced Audit Trail

Monitoring the accessibility of patient info ensures the software protects the patients’ protected health information (PHI). Sage Intacct’s Advanced Audit Trail can follow the path and edit the history of a given record. Cloud software is known for its ease of accessibility from different devices. Sage Intacct accounts for this by logging all types of file access, including lists and dropdown views, inclusion in reports, and the use of third-party software. In addition, advanced Audit Trails can track file access for contacts, vendors, and patient records. 

EMR Integrations

Don’t worry about Sage Intacct not synching with your existing electronic medical record (EMR) programs. Sage Intacct’s open API means it pairs well with other programs that your company may use. For example, if your practice works with software like MatrixCare or Hybrent, you’ll find it easy to synchronize those solutions with Sage Intacct. 

Sage Intacct integrates with your current EMR system, ensuring data transferred between software is secure. In addition, the developers at Sage Intacct have taken steps to protect data flowing through the API; integrations are safe and compliant, offering high-level protection for your PHI. 

Additionally, If you want to shift from your current software as you transition to Sage Intacct, you can check out the Sage Intacct Marketplace for healthcare industry add-ons.  


One of the essential elements of HIPAA-compliant accounting software is the level of security provided. The cloud is known for its overall high-level security, but Sage Intacct goes forbye to protect your data. Sage Intacct partners with Avertium to achieve protection that is certified HIPAA- and HITECH-compliant. Your software will also update quickly and automatically to keep you on the latest, most protected version of the software.



What are medical claims?


What are medical claims, and what do you need to know

Medical claims are the most critical data sources for healthcare businesses. For each billable patient visit, all-payer claims include complete diagnostic and procedure information. This claims healthcare organizations may use data to track referral trends, improve healthcare quality, boost sales, and enhance their go-to-market strategy.

All of this can be difficult to accomplish without a thorough familiarity with medical claims data. If you do not work in the medical sector, the medical insurance claims procedure might be highly complicated. However, it is critical to understand the processes a claim takes to know what to expect and how to deal with any difficulties.

medical claim

Today in this article, we are going to discuss what is meant by medical claims, how to file medical clam, the steps of the medical claim process, and so on. So here we go.

What is the medical claim?

A medical claim is a reimbursement request sent by your healthcare provider to your health insurance company. It outlines the services provided. And it guarantees that the doctor is paid, that your insurance covers the covered benefits that you are invoiced for the remaining. A claim is initiated the moment a patient arrives for an appointment. It tracks a health service from its inception till the patient gets and pays the final bill.

In the case that the patient visits a doctor who is not in their network, claims might be submitted by the patient. However, claims are immediately sent to insurance by the healthcare practitioner following an appointment or other service in most cases. You may be confident that claims processing centers follow strict HIPAA rules to protect the safety and security of specific sensitive data.

Medical claims are made up of codes, usually Current Procedural Terminology (CPT) codes that define the medical services that you delivered to the patient. The medical codes define any service provided by a provider, such as:

  • A diagnosis
  • Medical supplies
  • Medical instruments
  • Transportation for medical purposes
  •  Pharmaceuticals as well as

How do medical claims work?

Following a patient contact, your practice is required to convert the services you delivered into CPT codes. These codes define the services described above that are routinely administered. Without them, medical claims would frequently consist of long practitioner explanations of delivered services, introducing inconsistencies. Rather, CPT codes allow payers to quickly assess the services you performed and whether the patient is insured.

Medical claims should also reflect the fees charged by your organization for each classified service. CPT codes do not affect what you may and cannot charge for your services – that is entirely up to you. The final question is whether the patient’s gains will result in the provider completely reimbursing you or delaying part – or all – of the patient’s payment to you.

How to file a claim on your own

More frequently than not, healthcare providers will transmit the claims to be handled directly. Following service, the physician’s practice will collect your claim, together with any pertinent information from any insurance paperwork you filled out, as well as the medical codes, and submit it to a claims processing department or third-party administration.

The insurance company will process your claim form, and you will be billed for any leftover costs after insurance coverage and physicians’ fees have been paid. If you see a physician, not in your network, you will almost certainly have to file a claim on your own. In that instance, the stages are as follows:

  • Use the appropriate claim form for your benefit plan. You may locate it by checking in with your insurance information on your insurance website.
  • If you complete it by hand, be sure your handwriting is legible and that you fill in the blanks correctly. However, you may complete this form online.
  • Include any required information, such as the date of service and medical codes obtained from your physician’s office.
  • Verify the time limit for submitting your claim following services, and be sure to do it before the deadline.
  •  Check to see if your insurance covers the treatments you had. If this is not the case, your claim will reject.
  •  Include a signed pre-approval form with your claim submission if necessary.

 What happens once you create a claim?

Once your claims are created, it is good to run them through claim scrubbers to catch any mistakes. Without this mistake detection, you may submit incorrect claims, resulting in payer rejections that necessitate resubmission. In addition, resending a claim adds to the workload of your administrative personnel and delays refunds, reducing revenue and cash flow.

The majority of claim scrubbers are automated systems provided by third-party medical billing firms. They’re frequently a part of clearinghouses, which are places where claims are finalized between the time you submit them and the time payers receive the bill. Technically, you can delegate claim scrubbing to your administrator, but the intricacy of CPT codes makes automation more trustworthy.

What exactly is a medical claims clearinghouse?

A medical claims clearinghouse acts as an electronic link between healthcare professionals and service users. Medical claims are transmitted to a clearinghouse by healthcare providers. Clearinghouses then process, standardize, and filter medical claims before delivering them to the payer.

This procedure aids in the reduction of medical coding mistakes and the shortening of the time it takes to get provider payment. If a claim has medical coding or medical billing errors or fails to fulfill formatting standards, the payer may reject it. This implies that the claim will be resubmitted, causing provider compensation to be delayed.

What are the claims processing steps?

To guarantee accuracy and acceptance, healthcare claims are processed through some procedures. The path of a claim begins even before you arrange an appointment. Because insurance does not always cover all treatments or procedures, it is critical to review your health insurance policy to see what is covered and where to go for in-network care.

You call and make an appointment after you know what is covered and have found a doctor. Almost shortly after you receive your care, your claim is processed. Following an appointment, the following are the processes a claim will go through until you receive a final bill.

  • Insurance receives a bill for service charges, excluding any co-pays made at the time of check-in.
  • A qualified claims processor will evaluate the claim, confirming the accuracy and comparing it to the insurance plan to determine whether or not the services given were covered by insurance.
  •  If the services obtained were covered by benefits, the insurance company will pay the claim in accordance with the policies. Based on your plan, they will pay the whole claim in full; else, the remaining balance will be invoiced to you, the patient.
  • Payments will be verified and added to your insurance plan’s coverage and out-of-pocket totals. 
  • Benefits are explained, detailing the services received, how much was covered by insurance, how much the providers paid, and how much remains to be invoiced.
  • You will be issued a final bill to pay.
  • Check the EOB and final bill before settling the claim to confirm everything is proper and billed appropriately. Balances do not always match due to a mismatched process code or another clerical error. Claims can be amended and corrected at no cost to you.

What happens if your claim is rejected?

An insurance claim may be declined for various reasons; however, just because it was declined does not imply it cannot be resolved. If you get a claim rejection notification, contact the relevant billing provider to discuss the reasons for the decision. Here are some of the most typical causes for claim denial.

  • The erroneous claim forms were delivered or completed improperly.
  • Treatments were administered to the patient without prior authorization.
  • Insurance does not cover the service since the claim was submitted too late.
  • Medically unnecessary services were provided.

If such are the reasons a claim was refused, try to settle it over the phone. If a claim cannot be settled, it might be sent to the insurance provider for official evaluation. They can examine the claim in further depth. They will then either reverse the decision or decide that the claim may be resubmitted with the necessary facts to be accepted.




Athenahealth medical billing software Features, pricing & Overview

Athenahealth medical billing software Features, pricing & Overview

Athenahealth medical billing software Features, pricing & Overview

Athenahealth is a software that comes with a wide range of billing tools to make medical practice management easier. Athena Healthcare has introduced you to several modules. Like all other medical billing software worldwide, Athenahealth provides billing features such as graphing disease data and scheduling. This software is the best option for managing all data with a prime performance indicator for medical practices.

What is Athenahealth Medical Billing Software?

Athenahealth is a cloud-based clinical solution designed to streamline medical practice management and to report. The primary purpose of Athena Health is to relieve you of all administrative duties other than the patient’s work in the medical office and to save you time to pay full attention to the patient. With a host of features such as e-appointments, telehealth services, patient portals, and appointment schedules, Athenahealth is more uniquely designing like other medical billing services.

Industry stability

The medical billing software industry is now successfully reaping the benefits around the world. As a result, healthcare professionals worldwide have used Athenahealth medical billing software for more than 20 years. As a result, Athenahealth is one of the ten most sought-after software for medical training in the United States.

common benefits of Athenahealth

  1. Time management
  2. Increased revenue
  3. Bill management
  4. Quality service
  5. Compliance with laws and regulations
  6. Increased patient satisfaction

Key Features Review

• Customizable templates

Athenahealth Medical Software has a custom template system that allows you to manage your bills that are adding daily, weekly, or monthly. Those systems are unlimited to each record. When much patient data is being collected, There is a filter to extract only the information you need.

You may have recurring reports that you need to apply monthly or weekly on bills and medical claims. In managing such records, Athenahealth’s customized template system is even more critical to make it easier to track your total income or recurring expenses and days.

• Reporting Dashboard

The Athenahealth Medical Software Reporting Dashboard represents the criteria for accounts. They are the collection of time and payments in the accounts receivable. The unique function of the bulletin board is to report rejections or canceled bill reports so that you do not miss them. In addition, the Athenahealth Dashboard also provides medical billing reports on your regular customer payments or full payment.

Athenahealth gives you an idea of ​​the essential quality by automatically comparing it with the average measurements of the Athena Net. It allows you to identify non-promotional aspects and gain an understanding of the areas that are coming down. Athenahealth offers you the opportunity to join a series of consultations and contact the company if the standard falls short.

• Scheduler and Appointment Calendar

We mentioned earlier that Athenahealth had introduced several modules. First, it offers a precious calendar by Athena Clinical. It allows you to monitor the training schedule of the medical office staff easily, whether weekly, daily, or monthly. As the main point of the appointment calendar, every other appointment in the medical office per day is shown with information. In addition, The calendar displays the type of appointment, attendance status, patient personal data, etc., with a photo of the patient.

In medical practice, you need to manage patient appointments. To help with that, Athenahealth has introduced a timekeeping tool. The software has an easy-to-use tool to track the number of patients at a given time. In addition, It could make it easier for you to book new appointments through it.

Athenahealth Medical Software allows you to monitor scheduled appointments along with patient-related bills. The timetable also allows patients to update their data and present their needs before making an appointment. Finally, you can use patient A / B testing tools to drive patient appointment reminders. Use telephone lines, emails, or text messages.

• Claims

Athenahealth manages E&M codes through medical bills and displays the charge to you. In short, Athena Health offers an accurate overview of ICD-10 and CPT codes. This medical software captures all of your billing rights in as little as eight seconds. Athena Health also pays for these rights in less than three working days.

In addition, Athenahealth offers a clear review to verify the accuracy or omissions of the payers concerned. For example, if 95% of the requests are completed within three working days. Meanwhile, the software also allows you to get a full refund if certain rights are denied.

• Patient portal


Athenahealth medical billing software Features pricing & Overview
Photo credit- PicsHealth. blogpost. com

First of all, the patient portal of Athena health medical software is HIPAA compliant. Any patient can contact the medical staff at any time using that messaging tool. You can task such as notifying patients of payments and meeting appointments quickly through the patient portal. The patient portal is more critical for the patient to make an appointment to see the doctor, receive medication, know the laboratory results, and communicate safely.

Patients also can use the patient portal for tasks such as obtaining and completing bill payment forms. Through the patient portal, physicians or healthcare professionals also have the opportunity to launch an institutional vocabulary with their logo. Connect with the patient quickly and online through the Athena Health portal.

• Recording

There is no need for office staff to type patient data separately.
With Athenahealth, you will soon have access to patient data and historical information, demographics, and whenever you want to know. This software can organize and store all data on a customizable template system. In addition, Athenahealth provides voice recording information. This system allows you to detect the previous diagnoses easily, complete prescriptions and allergies.

• E – Recommendations

We introduce you to Athena Clinics as Athenahealth Recording Tool. You can place your orders electronically at Athena Clinical. There is an opportunity to make things like medicine or lab orders through e-recommendations. The ios mobile app gives you the chance to manage any hospital activity you want from anywhere in the world.

• Telehealth convenience

Athenahealth’s telehealth feature has been upgraded to Covid-19 status. In that EMR tool, patients can easily make medical appointments through technology. Patients do not need to connect to other software for this. Telehealth makes it easier to see a doctor using any device. In Athenahealth, telehealth has created opportunities for the patient to observe the disease, self-monitor the patient, and facilitate communication with the physician.

• Interaction

Athenahealth’s interactive tools allow you to transfer patient data to other providers quickly. There are a large number of interactive tools in medical software. It also allows you to add new data to patient data records without any hassle. In addition, these tools in Athena Medical Software are more relevant to the standards and regulations set by programs such as Medicaid EHR and Medicare.

Therefore, it will be quiet for you to make transfers and patient transactions without hassle as per the rules and regulations like the prescribed MACRA and MIPS. In addition, you can integrate with the public well to access websites such as Epic and Cerner.

• Customer service and support

Customer service and support of Athenahealth medical billing software are available to you at any time by phone or email. Contact the Account Manager at 1-800-981-5084 to discuss your issue. You can also arrange a direct appointment with him. In addition, Athena Health has an email box open for live chat or support requests, unlike other medical software.


Overall, the cost of Athena’s health software is $ 140 per month for Athena clinics EMR. If you want a complete healthcare technology kit, you must sign up for a medical billing service. Monthly savings prices can vary from 4% – 8%, depending on revenue cycle management. Athena Health’s pricing is based on document management, patient contact platform, and revenue management.

Establishment and process

As with most medical billing software, Athenahealth does not charge a fee for primary health care. Therefore, it does not take more than a month to implement. But if you get reports on an external platform, it may take you a while longer. However, you have the opportunity to pair with an account agent without any problems while installing the software. In addition, you can contact your agent to help you succeed throughout the process.

Athenahealth Limitations and Disadvantages

Athenahealth customer support can sometimes be a bit weak. External revenue cycle management is not allowed here. Access to the tools of this medical software can be a bit troublesome.

When it comes to the interface, the interface is not as intelligent as other medical software. The user also feels that it is a bit difficult to enter their data into the platform. In addition, nearly 70 percent of consumers say the language is a bit difficult to interpret for a claim.


Who is best suited to use Athenahealth?

Athenahealth medical software is especially suitable for medical training of 10 to 50 employees. These mediocre practices earn between one and ten million dollars a year using the software.

Does Athenahealth have an EHR?

Athenahealth EHR offers organizations that want to increase revenue through medical practice and provide the highest level of health care. You can choose the EHR as an option to improve revenue management and patient satisfaction in the course.

Which clearance housing does Athenahealth use?

Athena EDI solves all payment problems before they arise. In addition, Athena ED Clearance Center is fully integrated with Athenaidx.

Behavioral Health Integration


Webinar series on Behavioral Health Integration: Billing & coding

The pandemic of COVID-19 now has a significant influence on Behavioral Health Integration in the United States. Indeed, the epidemic is one of the reasons why physician groups created the Behavioral Health Integration Collaborative this past autumn. The collaboration is intended to integrate behavioral and mental health into total health care. And to enhance patient access to behavioral health by providing physicians with the resources, they need to provide these services in a healthcare setting.

In this article, we are going to discussed Behavioral Health Integration. Suppose you do not have any sound knowledge about this. So do not worry, let’s see what Behavioral Health Integration is? And what are the highlights of the webinars held this year?


Experts in the field of medicine explain how to bill and be reimbursed for behavioral health care services. This webinar will emphasize how providing these services is a worthwhile use of physician time and effort and offer a general overview of mental health billing and coding. Physicians are given accurate and practical information as well as real-world examples.

The Behavioral Health Integration Collaborative is creating an online compendium that will give the combined resources of eight national professional organizations to help professionals navigate the hurdles to successful behavioral and mental health integration. The compendium will be a one-stop online collection of medical professional materials that provide a tried-and-true method for administering behavioral and mental health treatment in primary care settings.

As the compendium expands, it will be endorsed by free access to online webinar programming, remote learning opportunities, and other resources with important steps, practice guidelines, and tools to speed up behavioral health integration, such as facilitating collaborative cultures and strong patient engagement, supporting accurate billing and coding, and integrating telehealth into practice.

The collaboration has created a series of free webinars titled patient’s individual’s coming Obstacles” during the previous few months. It assists physicians in delivering physical and behavioral health care both during and after the epidemic. To date, the collaboration has released five webinars on subjects ranging from billing and coding to leveraging telemedicine to give virtual behavioral health assistance and tackling the stigma associated with mental and behavioral health disorders.

What is Behavioral Health Integration?

Behavioral Health Integration combines medical problems and related behavioral health variables that impact health and well-being in a single environment. Behavioral integrated health care, a component of whole-person care is a fast-growing change in the delivery of high-quality health care. And also this is a critical component of the advanced patient-centered medical home.

Behavioral Health Integrated is also known as integrated care, integrated behavioral health, collaborative care, or primary care behavioral health. Whatever it is called, the aim is the same: improved care and wellness for the entire person.

Integrated behavioral health care providers recognize that both medical and behavioral health factors impact an individual’s entire health. Therefore, to address a patient’s issues, medical and behavioral health practitioners collaborate as a team. 

When patients desire or require specialized treatments, these integrated teams provide care in the primary care environment. The benefit is improved collaboration and communication while engaging toward a standard set of overall health objectives.

Specifications for the Compendium

The collaborative’s most recent project has resulted in the development of a new tool for physicians engaged in incorporating behavioral health into their practices. The BHI Compendium, released in December, supplements the webinar series by offering extra resources and information on the integration process. 

The BHI Compendium is divided into 12 chapters, each of which addresses a distinct aspect of behavioral health. Among its chapters are those that address models of care, assist practices in assessing their preparedness to apply BHI and establishing success measures, and investigate various methods to financial stability.

Every chapter has at least one external resource link. Furthermore, the compendium includes a “Resources & Tools” section with connections to over 60 online tools, reports, and published papers. Physicians are also encouraged to provide more materials and offer comments on how future editions of the compendium may be improved.

Billing and coding Behavioral Health Integration (BHI) webinar highlights

The Behavioral Health Integration (BHI) Collaborative hosted the second webinar under the Overcoming Obstacles webinar series: “Billing and coding”. There were some highlights on the webinar. They are as follows,


  • The series is part of the BHI Collaborative’s continuous efforts to provide professionals with the information they need to provide a whole-person, integrated, and comprehensive approach to physical, mental, and behavioral health treatment in their practices throughout the COVID-19 epidemic and beyond. 
  • From behavioral health professionals offering expanded services inside health services to a true collaborative healthcare setting in which you truly operate as a united care team for the benefit of patients.
  • Whenever your organization considers how to organize your practices and what works best, there may be a number of options depending on your practice’s skills and capacities to provide this standard of care to your patients.
  • Such webinars are the result of a collaboration between eight of the nation’s premier professional organizations, which were formed to stimulate the successful and long-term integration of mental and behavioral health care into medical practices.
  • Including an initial focus on critical care, the BHI Collaborative is devoted to providing a professionally rewarding, sustainable medical practice experience and will work as a trustworthy partner to assist overcome the hurdles that get in the way of serving patients’ mental and behavioral health requirements.
  • The behavioral care manager collaborates closely with the patient and the prominent care physician to organize care, monitor treatment compliance, and really own the care plan.
  • However, the behavioral care manager plays a vital role in coordinating treatment recommendations between the behavioral care manager, the PCP, and the patient, in collaboration with a consultant psychiatrist, who is frequently a third-party hired psychiatrist who works off-site.
  • The study on integrating behavioral health points to several options to solve behavioral health staffing constraints and the possibility for integrating behavioral health into healthcare coverage. And, without a doubt, COVID has raised everyone’s understanding, as well as the necessity for mental health treatments to be provided in addition to medical care. So they’re extremely convergent right now.
  • Every interaction involves time spent by the behavioral care manager with the primary care provider, the consultant psychiatrist, and the patient. Essentially, everything that can be defined as the provision of behavioral health care is theoretically billed. 
  • Begin receiving a lot of CPT codes from what is known as our medical division. And this is significant because, in this situation, CPT codes in the assessment and management area are accessible to be submitted by clinicians and other qualified health care providers.
  • Additionally, payment for collaborative care is collected and invoiced monthly for program participation at the end of every month rather than charging for required visits.

The American Medical Association, the American Psychological Association, and other leading medical organizations have formed the Behavioral Health Integration (BHI) Collaborative, an organization dedicated to catalyzing effective and long-term integration of behavioral and mental health care into health care professional practices. As a result, APA members are invited to attend these webinars, which will be stored for later viewing. 

The following are the topics:

  • Collaboration and a Shared Culture Are Important in Behavioral Health Integration
  • 101 in Behavioral Health Billing and Coding How to Earn Money
  • Top tips: Simulated Behavioral Health Integration Implementation Strategies
  • Strategies for Evaluating the Financial Impact of BHI Implementation
  • How Professionals Can Take the Lead in Breaking Down the Behavioral Health Stigma Treatments and Diagnoses
  • Definition of crucial privacy and security rules allowing for safe and secure communication and information flow between members of the Incorporated Care Team

Medical Billing Outsourcing Is On The Rise

medical billing outsourcing

Medical Billing Outsourcing Market

The COVID-19 pandemic and struggle in hiring employees have increased medical billing outsourcing in the healthcare industry. Although recruiting the services of outside firms can be a better option, practices should be aware of some critical thoughts.

Staffing inadequacy, closures, quarantine, and employee virtualization have all conducted many practices to outsource billing services to a company that can take on the management and human resources weight.  Medical billing outsourcing companies often charge a percentage of the income received, which can be cheaper than employing in-house billing personnel.

medical billing outsourcing

Medical billing outsourcing can be a sensible option in today’s environment. Outsourcing might help to reduce the additional cost of employee income. In terms of investments, the average employer pays $4,000 and 24 days on hiring a new employee, and the average expense of replacing an employee is between 16% and 20% of that employee’s salary.

Outsourcing can give more flexible talented employees to increase and decrease without additional cost and a massive workload on the organization. However, practices should be careful in which billing operations they outsource to make sure they can be worked on quickly and in a way that improves the grounded level.

As said, medical billing outsourcing is outsourcing the billing process of medical institutions or hospitals. It involves utilizing a third-party software application to process bills, file and follow up on medical insurance claims and gain correct payments for the services provided.

More Direct Collections From Patients

In recent years, medical billing organizations have had to change their collection practices in light of a rise in high-deductible medical plans that have increased patients’ medical care charges. So, in addition to presenting claims to insurance agencies, organizations frequently have to look for payment directly from patients. 

Collecting money from patients is an entirely different situation requiring soft skills, provident communication, and established technology. The old ways of billing and collecting don’t work anymore. Much of the medical billing work used to happen after the appointment. Now, what happens before the meeting can be even more essential to prevent the later problems.

Medical billing outsourcing can limit practices’ capability to work out payment arrangements with financially secured patients. For example, a person with an outside billing company handling collections fails flexibility in fixing up payment plans with patients and the option of not take payment from poor patients. They don’t like outsourcing billing because they know that some patients’ environments and financial situations are not better.

Areas of Concern

Medical practices need to think about some crucial things when outsourcing medical billing. For example, they could be responsible for a billing company’s mistakes. With any salesperson relationship, there are risks. Even if infrequent, there can be security breaks and HIPAA breaches.

While violations of HIPAA privacy can happen with in-house billing, the risk is possibly greater and harder to manage when it outsources. Medical practices must get real-time documents from medical billing organizations. Monthly reporting is no more acceptable, but sadly, most RCM organizations can’t make real-time actionable marks that let the provider hold them accountable.

In addition, some billing companies outsource services to other countries, which causes slow-downs, problems with the timely filing of claims, and communication barriers.

The COVID-19 pandemic is waiting to have a hugely positive effect on market growth. Technology is one of the main factors in today’s medical care systems, including localized healthcare systems that existed earlier. 

Therefore, the digital development speeds up by the COVID-19 pandemic is expected to impact the market studied crucially positively. This pandemic situation has thoroughly established the need for active action and the foundation of a robust, collective, scalable, and agile digital medical care framework.

As a result, many organizations are now building up a new pathway, like embrace digitization and outsourcing non-core aspects of their businesses, such as billing and accounts, which expect to increase the market growth. 

Furthermore, a sudden shift toward digital billing was observed during this period, hoping to drive market growth. Moreover, consumer interest has increased remarkably regarding online bill payments since the pandemic, leading to a more significant market for medical billing outsourcing. However, it makes a non-core business operation for most medical care organizations.

Medical billing outsourcing services need to hire a medical billing service provider outside the practice to do all the billing work, often giving a fair percentage cut of the total income generated.

The worldwide medical billing outsourcing market is expected to reach USD 25.5 billion by 2028, growing at a CAGR of 12.2 percent between 2021 and 2028.

Medical Billing Outsourcing Market Report Highlights

  • The outsourced segment accounted for the largest revenue share in 2020 and expect to witness a high CAGR attributed to the rising preference of hospitals, physician offices, and startups choose for outsourced medical billing services for free and easy claim management at low expense.
  • In 2020, the front-end services sector led the market. However, the middle-end services section is assumed to register the most leading CAGR across the prediction period due to the growing demand for Revenue Cycle Management (RCM) services offering Electronic Health Records (EHR) software.
  • Hospitals, possessing higher claim volumes, accounted for the largest revenue share in the market in 2020 and are estimated to maintain the authority even during the estimated years.
  • In 2020, North America had the highest revenue share. It project to expand further as the U.S. has testified a change in the medical care system with the introduction of ICD-11 coding in 2019 and a requirement from the government to include the Electronic Medical Record (EMR) management system.
  • Medical billing and Revenue Cycle Management (RCM) companies offer successful implementation of EMR at the practice level and assume to transform the market.

North America will expect to continue its lead over the forecast years. Becoming the highest market assigns high realization levels about outsourcing medical are technology services and the robust existence of well-known market players in the region.

The front-end section of the market contains the main functions of medical billing outsourcing and includes methods such as scheduling, preregistration, certification, qualification, insurance verification, and pre-approval. However, due to the entry of new market players and the growing understanding among medical care companies, middle-end services are expected to behold the fastest growth in the prophecy period.

End-users of the market are hospitals, clinic centers, and others. Because hospitals were the major consumers of such services due to high claim volume, the hospital category had the greatest revenue share of more than 44.0 percent in 2020.

In addition, the request for outsourcing is high in hospitals, as an alliance of hospitals further increased the problems of billing and repayment methods. At the same time, the physician office segment accounted for the second-largest revenue share in 2020 and is supposed to grow at the fastest rate over the prophecy period. 

This growth is due to rising expenditure on medical care by small and medium-sized medical care anticipated providers, the growing importance of risk management, regulatory conformity, and complex technology and staffing requirements.

Several medical care providers in the U.S. depend on outsourcing companies to manage their billing processes, maximize operating margins and manage high-volume transactions. Moreover, as outsourcing companies are being standard worldwide, developing regions such as the Asia Pacific and Latin America are expected to register a promising CAGR through the prophecy period.

As the International Classification of Diseases-10th edition (ICD-10) has made the medical billing industry even more complex, the demand for revenue cycle management (RCM) has risen. Also, providers are selecting organizations that contribute the correct combination of RCM with electronic medical records (EMR) for improved patient outcomes.