In-network billing services
In-network means the payer has agreed to your rates. We make sure the payment reflects that agreement.
Being in-network means the payer has agreed to a contracted rate for the services you bill. The claim still has to match that rate. When it goes out at the wrong rate, without a required modifier, or before credentialing is confirmed, the payer denies it or pays it short. Nobody flags these errors at submission, so they surface only when the payment comes back, and practices end up absorbing the loss.
Our billers at MedHeave make sure your contracts work the way they were meant to. We verify credentialing before a claim goes out, bill at the exact rate agreed upon with the payer, and stay on the claim until payment is received. As a result, 98% of our claims clear on the first pass.
Our operational footprint
These aren't aspirational targets.
These metrics are what we deliver, consistently, across all practices and specialties we work with.
98%
70 to 80%
24–48
1 business day
Having a contract with a payer does not mean every plan they hand you comes with the same deal.
Being in-network with a payer does not automatically guarantee agreed-upon rates. Your reimbursement rates depend on the specific plan, and you only get them when you hold a signed, active contract for that plan. Take Cigna. Its PPO and HMO plans can have different rates and billing requirements, and a contract with one does not carry over to the other. Assume it does, and the payer denies a clean claim as out-of-network or pays it at the wrong rate.
Our dedicated account managers at MedHeave check network status before the claim goes out. We verify the payer, the specific plan, the provider's credentialing status, and the contracted rate tied to that network. If the network status or rate does not line up, we identify it before it turns into a denial or an avoidable underpayment. Once the claim is ready, we bill it against the correct allowed amount and contracted rate from day one.
Your revenue rarely disappears all at once. It leaves in small amounts that are easily overlooked.
An in-network contract sets the rate, but it does not make sure you get paid at that rate. A wrong modifier, missed detail, or billing error can turn an otherwise clean claim into an underpayment. One claim may not seem significant on its own, but repeated across hundreds or thousands of claims, those small gaps can add up to substantial revenue left uncollected.
Underpayments that slip through
A contracted rate sets the amount a payer owes for a service. The payer sometimes pays a different amount. Few practices compare the two on every claim line, so the shortfall goes unnoticed and stays unpaid for months at a time.
Modifier errors on claims
Credentialing gaps at submission
A claim goes out before enrollment with a payer is fully verified and confirmed on file somewhere. The payer denies it purely on status alone, not on the quality of care actually delivered to the patient.
Downcoded visit payments
When the visit notes do not support the level that was billed, the payer downcodes the claim and pays for a simpler visit. The payment comes in lower, and the gap rarely gets flagged unless someone checks for it directly.
Coordination of benefits disputes
Two insurance plans can each decline to take primary responsibility on the very same claim submitted. The claim then stalls until someone steps in to correct it, and that someone is rarely the payer itself.
Group practice duplicate denials
Two providers within the same group see patients on the same day, in the same facility. Payers sometimes flag one visit as a duplicate of the other one, and the claim stalls until that gets disputed properly.
Your front desk has patients to deal with. Denials can come to us instead.
Claims submission and follow-up
We submit every claim coded and checked against the payer contract. Our team follows each one through adjudication and pushes for payment instead of waiting for a status update to arrive on its own.
Eligibility and verification of benefits
We verify eligibility, benefits, and network status directly with the payer before the appointment. To keep claims from being billed against an inactive plan, we confirm coverage activation with the payer, not just what is on file.
Charge entry and coding
We recheck every charge against the documentation on file and flag any coding errors to the provider before the claim reaches a payer.
Payment posting and reconciliation
We post every ERA/EOB and reconcile each payment against the expected reimbursement, not just the payment received. Our billers flag any shortfall the same day it appears and identify the cause.
Patient statements and collections
The practice collects copays at the time of service. Once the payer processes a claim, we send the patient a statement for the coinsurance or deductible balance the payer assigned to them.
Prior authorization support
We track prior authorization requirements before the visit happens. A miss is unlikely, but if one does occur, our experts check for a retro authorization first and file a medical necessity appeal when that option is not available.
You probably know you’re leaving money behind. We can help you put a number to it.
A contracted rate only means something if every claim actually gets billed and paid to it. This calculator estimates what your practice might be leaving uncollected each year from underpayments, denials, and claims nobody circled back to collect.
Fill in your details and click Calculate now to see your estimate.
Procedures we bill for
Office visit and E/M claims
Preventive and wellness visits
Diagnostic and lab claims
Minor in-office procedures
Specialist referral visits
Telehealth encounters
Same-day multi-provider visits
Ancillary and DME claims
Experienced across 40+ EHRs. We work natively within your system and never route patient data through third-party tools.
Our process
Submitting the claim is where the process starts, not where our job ends.
Eligibility and credentialing check
Before the appointment, our billers confirm with the payer that the patient's coverage is active and that the provider is enrolled for the patient's plan. That rules out claims billed against an inactive policy or before credentialing is confirmed on file.
Charge entry and audit
Our team enters the charge from the superbill. The practice supplies the coding, and we review it against the documentation and advise the provider on any errors. Before the claim is submitted, we run a live audit against the payer's guidelines and the fee schedule tied to that contract.
Claim scrubbing
We run every claim through a scrubbing process before submission. Data entry errors get caught here, not after a rejection, and we correct anything that could stall the claim further down the line.
Submission and rejection handling
We submit the claim to the clearinghouse within 24 to 48 hours. If it is rejected before reaching the payer, our billers identify the rejection reason, fix it, and resubmit within one business day.
Adjudication and payment posting
Once the payer processes the claim, we receive the ERA or EOB and post the payment right away. We match every line against the contracted rate.
Denial management
Every claim is verified before it goes out, from coverage to enrollment to charges, so it is approved the first time. If a claim comes back denied, our billers rework it until it is approved.
A wrong modifier does not look like much until the payer uses it to change the payment.
Underpaid claims that go unflagged
When a payer pays less than the contracted rate and no one checks, the claim is closed as paid. The shortfall is never followed up, so that money is lost. Nothing was flagged, so the same shortfall keeps coming through month after month.
Modifier errors that repeat across claims
A missing or mismatched modifier rarely affects just one claim. Every claim for that service carries the same error, so each one denies or pays the wrong amount until the practice corrects the modifier.
Credentialing gaps that spread past one claim
A lapse in enrollment does not affect just one claim. The payer denies the claims for services the provider performed while enrollment was inactive, so every claim from that period comes back denied.
Downcoding that resets the baseline
One weak note can get a visit type downcoded. After that, the payer can start applying the same scrutiny to similar claims from that practice going forward, and the lower payments add up.
Duplicate denials that double the work
When two providers in the same group see patients the same day, a payer flagging one visit as a duplicate does not just stall that claim. It stalls both, and both now need a dispute filed for care that was entirely legitimate.
We didn't write these case studies to brag.
Okay, maybe a little.
Who we work for
We work with practices that have outgrown the “same process for every payer” approach.
A signed contract sets the rate a payer owes for each service. It does not check the payments that follow. Unless a biller compares each payment to the contracted rate line by line, an underpayment looks like any other payment, and practices often go months without noticing.
Practices with a mixed payer panel
Our billers work with practices contracted with multiple payers at once. Each payer has its own contracted rate and its own modifier rules, so a claim that is correct for one payer can be wrong for another. That is why our billers check every claim against the rules of each payer specifically.
Practices adding new payers or plans
A new contract does not mean claims can go out right away. Enrollment has to be confirmed on file for that plan first, and claims billed before then are denied. Our billers confirm enrollment with the payer before the first claim goes out.
Group practices billing multiple providers
We bill for groups where two or more providers see patients on the same date of service. Payers sometimes deny one of those claims as a duplicate. Our billers check that each claim lists its own rendering provider, so separate visits are not treated as one.
Practices absorbing shortfalls as routine
Multi-location practices
Our billers work with practices operating across multiple locations, where Network status and contracted rates can differ by location. We confirm with the payer that the provider is enrolled where the services were performed.
Why MedHeave
Assuming a payer will pay the claim in full is optimistic. We prefer not to take their word for it.
Submitting a claim and hoping for the best is not our strategy. Our billers verify coverage and enrollment before a claim is submitted. They compare the payment to the contracted rate when it arrives.
98% first-pass acceptance
Before a claim reaches the payer, our billers put it through three checks. They confirm the patient's coverage is active, confirm the provider is enrolled for that plan, and audit the charge against the payer's guidelines.
80% denial overturn rate
When a payer denies a claim, our billers start with the denial reason. They take the corrective action the payer requires and stay on the claim until the payer reverses its decision. That work has reversed 80 percent of the denials we handle.
Underpayment prevention
Our billers set charges above the payer’s expected reimbursement amount, creating room for underpayments to still land closer to the contracted rate. This helps prevent small payment discrepancies from slipping through unnoticed.
Same-day correction turnaround
When a claim requires correction, our billers review the issue, make the necessary changes, and resubmit it to the payer within one business day. This keeps the claim moving through the payment cycle instead of adding another delay to reimbursement.
Transparent performance reporting
We track collection rates, denial patterns, and payment trends in monthly reports built for each practice. Every report gives your team a clear view of what is being collected, where issues are recurring, and what needs attention.
Compliance-first coding
Our coders review the documentation and ensure every code reported is supported by the record. This keeps the documentation, coding, and claim aligned.
FAQs
Let us answer some of the questions you were going to ask in that first email.
What is the difference between in-network and out-of-network billing?
How does in-network reimbursement actually work?
What is the difference between an allowed amount and a billed charge?
What is balance billing, and when is it not allowed?
How does the No Surprises Act affect in-network billing?
Is in-network billing simpler for HMO plans?
HMO plans tend to have narrower networks and stricter referral rules, so eligibility and authorization matter more upfront. Once a claim clears those checks, billing itself is not automatically simpler.
How should a practice handle an underpaid or denied in-network claim?
Start by reviewing the EOB or ERA against the payer contract to understand why the claim was not paid as expected. Once the reason is clear, the practice can determine whether the claim needs to be corrected, the payment disputed, or additional information provided.
A claim does not get a participation trophy for making it into the system. Someone still has to get it paid.
