Hospital billing operates in a completely different regulatory universe from physician billing. UB-04 claims, DRG optimization, revenue codes, condition codes — it requires specialists who live in this world daily.
These two billing environments have entirely separate code sets, claim forms, and reimbursement structures. We are experts in both.
CMS-1450 (UB-04) · ICD-10-PCS · DRG-Based Reimbursement
Inpatient billing is complex, high-value, and DRG (Diagnosis-Related Group) driven. A single MS-DRG assignment can be worth $15,000–$80,000+ per admission. Accurate principal diagnosis selection and ICD-10-PCS procedure coding directly determines your DRG weight — and therefore your entire reimbursement for that stay.
CMS-1450 (UB-04) · APC-Based · OPPS Rules
Hospital Outpatient Prospective Payment System (HOPD) billing is governed by Ambulatory Payment Classifications (APCs) and strict CMS bundling rules. Packaging rules, composite APCs, and status indicator assignments all affect payment — and non-compliance creates significant audit risk.
Each step in the DRG assignment process affects your reimbursement. We optimize every layer.
Clinical query to capture all relevant conditions and procedures
Accurate procedure code selection with correct approach and device
Principal diagnosis chosen per UHDDS guidelines to maximize DRG weight
Complications and comorbidities documented to upgrade DRG tier
Clean UB-04 submitted with optimal DRG for full allowable payment
Correct inpatient vs. observation status determination.
Pre-emptive review of high-risk DRG assignments.
Proper UB-04 condition and value code assignment.
Inpatient Prospective Payment System rule adherence.
Hospital billing is unlike any other healthcare billing environment. The dollars involved per claim are significantly higher, the compliance risk is greater, and the complexity of charge capture — across dozens of departments — makes revenue leakage almost inevitable without specialized oversight.
Our hospital billing specialists conduct concurrent chart reviews during patient stays to identify documentation gaps before discharge — not after, when it's too late to amend the record.
We review and reconcile your charge master (CDM) annually to ensure all billable services map to current revenue codes and CPT codes — preventing systematic under-billing.
We facilitate compliant physician queries to clarify documentation that supports higher-weighted DRGs — adding specificity without altering clinical facts.
Hospital claims are high-value targets for payer audits and RAC reviews. We pre-screen high-risk DRGs before submission to prevent costly post-payment retractions.
We combine certified expertise with proprietary technology to deliver unmatched revenue cycle performance.
Our advanced rules-based scrubbing engine runs every claim against millions of payer-specific rules before submission, practically eliminating front-end rejections and accelerating your cash flow.
We don't use generalists. Your account is managed by specialty-specific certified coders who understand the nuances of your exact clinical discipline, ensuring maximum compliant reimbursement.
Stop waiting for end-of-month reports. Our proprietary BI dashboards give you real-time visibility into collection rates, A/R aging, and denial trends.
We work seamlessly within your existing software via secure, HIPAA-compliant VPNs. Zero data migration required, and zero disruption to your clinical workflow.
Switching billing partners shouldn't disrupt your cash flow. Our meticulously engineered onboarding process ensures a smooth, parallel transition.
We establish secure remote access to your EHR/PMS and map your existing workflows without interrupting your current team.
We audit your past claims to identify immediate revenue leakage, coding errors, and systemic denial trends.
Our rules-based scrubbing engine is programmed with your specific payer matrix and local coverage determinations to prevent future denials.
We take over day-to-day operations, instantly applying our optimized workflows to accelerate your cash flow and reduce days in A/R.
Common questions about our process, integration, and security.
Let us assess your current inpatient DRG performance and outpatient HOPD compliance. We'll identify what you're leaving on the table.
Schedule Hospital Billing Review