Industries We Support
Revenue Cycle Management & Medical Billing for Hospitals
Hospital outpatient departments and employed-physician groups balance professional-fee billing with facility claim requirements and outpatient Medicare rules. Our workflows are built for both sides of that claim.
Hospital Medical Billing Across Facility and Professional Claims
Hospitals bill on two tracks at once: UB-04 facility claims for the department and CMS-1500 professional claims for employed and contracted physicians. Afiable Solutions runs both tracks under one team so charges reconcile against the same encounter, revenue codes align with the chargemaster, and the two claims do not contradict each other in front of the payer.
- Daily charge reconciliation between the EHR encounter, chargemaster and billing system
- UB-04 facility claim preparation with revenue code, condition code and occurrence code review
- CMS-1500 professional claims for employed physician and hospitalist groups
- Clearinghouse edits plus hospital-specific scrubbing rules before submission
- Late charge, missing charge and unbilled account review on a fixed daily cycle
Medical Coding and Documentation Review for Hospital Departments
Outpatient hospital coding lives or dies on documentation. Our certified coders review operative notes, ED records, observation stays and ancillary services against OPPS and payer policy, and send documentation queries back to the provider rather than guessing at intent.
- Outpatient facility coding aligned to OPPS, APC grouping and status indicators
- ICD-10-CM, CPT, HCPCS and modifier assignment with NCCI edit checking
- ED, observation and same-day surgery coding with level-of-service validation
- Provider documentation queries with tracked response and resolution
- Monthly coding quality audits with error trending by department
Claims Submission, Payment Posting and AR Follow-Up
Once a hospital claim leaves the building, someone has to own it until the account reaches zero. Our AR analysts work aged inventory by payer and dollar value instead of alphabetically, so the accounts that carry the most cash are touched first and every touch is logged against the account.
- Electronic claim submission to Medicare, Medicaid, MCO, commercial and workers' compensation payers
- ERA and EOB payment posting with contractual adjustment validation
- Contract underpayment identification against negotiated fee schedules
- Aged AR worklists prioritized by payer, balance and timely filing deadline
- Documented payer follow-up with escalation into provider relations
Denial Management, Eligibility and Prior Authorization
Most hospital denials are created before the claim is ever submitted — at registration, eligibility or authorization. We work denials on two horizons: appeal the account in front of us, and report the root cause back to the department that generated it so the same denial stops repeating.
- Insurance eligibility and benefit verification ahead of scheduled services
- Prior authorization initiation, tracking and renewal before the date of service
- Denial categorization by CARC/RARC with root-cause reporting by department
- Clinical and technical appeals with supporting documentation packets
- Medical necessity and medical-records-request handling within payer deadlines
Credentialing, Reporting and Back-Office Support
Hospital revenue cycle work does not end at the claim. Provider enrollment gaps stop reimbursement entirely, and leadership needs numbers it can act on. We keep enrollment current and report performance in terms hospital finance teams already use.
- Provider credentialing, payer enrollment and re-credentialing calendars
- CAQH, PECOS and Medicaid profile maintenance for hospital-employed providers
- Monthly reporting on days in AR, denial rate, clean claim rate and net collections
- Payer-level and department-level performance breakdowns
- Back-office support: patient billing enquiries, statements, refunds and record requests
What We Focus On
Workflows shaped around the payer rules, documentation requirements and operational realities of this care setting.
- Pro-fee and outpatient facility billing (CMS-1500 and UB-04)
- OPPS-aligned outpatient coding and edits
- Contract underpayment review against negotiated rates
- Structured denial management with root-cause reporting
- Escalation paths into payer provider relations
Outcomes Our Clients Track
Recovered contract underpayments
Reduced outpatient denial volume
Cleaner facility and pro-fee reconciliation
Services Included in This Support
Each function below can be delivered on its own or as part of full hospitals revenue cycle management.
Frequently Asked Questions
Does Afiable Solutions handle both facility and professional hospital billing?
Yes. We prepare UB-04 facility claims for hospital departments and CMS-1500 professional claims for employed or contracted physicians, and reconcile both against the same patient encounter.
Can you work inside our existing hospital systems?
Yes. Our teams work in the hospital's existing EHR, billing system and clearinghouse rather than requiring a platform migration. Access is granted under your own user controls and audit logging.
How do you handle hospital denials?
Denials are categorized by CARC/RARC code, appealed with the supporting documentation the payer requires, and reported back by root cause and originating department so recurring issues can be corrected upstream.
Do you support prior authorization and eligibility verification?
Yes. We verify eligibility and benefits ahead of scheduled services and initiate, track and renew prior authorizations before the date of service to reduce authorization-related denials.
What reporting do hospitals receive?
Monthly reporting covers days in AR, denial rate, clean claim rate, aged AR by payer and net collections, broken out by department so finance and operations leaders can act on it.
Discuss Your Organization's Revenue Cycle Needs
Talk with a specialist about billing, coding, AR or credentialing support for your organization.