100+

Hospital's

100+Clients

10yExpertise

100%HIPAA

Medical Billing and Revenue Cycle Management: Stop Leaving Money on the Table

Medical billing in the United States is one of the most complex, regulation-dense administrative systems in any industry. ICD-10 codes. CPT codes. HCPCS codes. Payer-specific billing rules that change quarterly. Prior authorization requirements that vary by payer, plan, and state. Timely filing deadlines that differ across hundreds of insurance contracts. Coordination of benefits for dual-eligible patients. The list of ways a claim can be denied - and revenue lost - is almost endless.

Most healthcare organizations are not losing money because of poor clinical care. They are losing it in the billing office - through claim errors, slow follow-up, inadequate denial management, and RCM processes that were designed for a simpler time.

ForNex Health provides end-to-end medical billing and revenue cycle management services powered by AI-driven automation, 10+ years of billing expertise, and a dedicated team of certified medical billers and coders. Our clients consistently see denial rates drop below 5 percent, days in accounts receivable shrink by 30 to 45 days, and net collections increase by an average of 40 percent within the first six months.

The Financial Reality Facing US Healthcare Providers Today

The average US physician practice has a claim denial rate between 5 and 25 percent - and only 60 percent of denied claims are ever reworked and resubmitted. The rest become pure revenue loss. For a 10-physician practice billing $5 million annually, a 15 percent denial rate that is not aggressively managed represents $750,000 or more in annual lost revenue.

Add to that the administrative cost of billing - which the Medical Group Management Association estimates at 14 to 15 percent of total practice revenue - and the financial case for a high-performance RCM partner becomes undeniable.

Our Services

Our Medical Billing and RCM Services

End-to-End Medical Billing

We manage the complete billing cycle for your practice or health system - from charge capture through patient collections. Our billers are certified (CPC, CCS, CBCS) and specialize by specialty, which means your cardiology claims are reviewed by someone who understands cardiac electrophysiology billing, not a generalist who handles every specialty the same way. Our billing workflow includes: patient eligibility verification before every appointment, charge capture review and scrubbing, ICD-10 and CPT code validation, claim submission to primary and secondary payors, ERA and EOB posting, patient statement generation, and collections follow-up.

AI-Powered Claim Scrubbing

Before any claim leaves our system, it runs through our AI-powered claim scrubbing engine - trained on millions of historical claims and payer-specific editing rules across all major US commercial payors and government programs. The scrubber catches modifier errors, unbundling violations, medical necessity gaps, and payer-specific formatting issues that would cause a denial - before the claim is ever submitted. The result is a clean claim rate consistently above 98 percent - compared to the industry average of 75 to 85 percent. Fewer denials mean faster payments and lower administrative cost per dollar collected.

Denial Management and Appeals

Denials are not just rejected - they are opportunities for revenue recovery if pursued correctly and promptly. Our denial management team categorizes every denial by root cause, initiates the appropriate remediation workflow, and tracks appeal status through resolution. We maintain payer-specific appeal templates for the most common denial categories across Medicare, Medicaid, Blue Cross Blue Shield, United Healthcare, Aetna, Cigna, Humana, and hundreds of regional plans. Our average appeal success rate is above 85 percent - compared to an industry average of roughly 60 percent - because we understand that effective appeals require clinical documentation, coding rationale, and payer-specific language, not just a generic cover letter.

Prior Authorization Management

Prior authorization is one of the fastest-growing administrative burdens in US healthcare. A 2023 AMA survey found that physicians spend an average of 14 hours per week on prior authorization activities. We manage the complete prior authorization workflow - submission, payer follow-up, peer-to-peer appeals, and documentation management - reducing the time your clinical staff spends on administrative tasks they were not trained to do.

Eligibility Verification and Benefits Analysis

A significant percentage of claim denials trace back to eligibility issues identified too late - after the service has been rendered and the claim submitted. We run eligibility verification for every scheduled patient, typically 48 to 72 hours before the appointment, and provide your front desk staff with a benefits summary that includes deductible status, copay amounts, and any service-specific authorization requirements.

Patient Collections and Balance Management

As patient financial responsibility has grown with the rise of high-deductible health plans, patient collections have become a critical RCM component. We manage patient balance communications through compliant statement generation, text and email reminders, and payment plan arrangements - with scripts and workflows designed to maximize collection rates while preserving the patient relationship.

RCM Analytics and Reporting

You cannot manage what you cannot measure. Our RCM reporting dashboard gives practice administrators and healthcare CFOs real-time visibility into: gross and net collection rates by provider and payer, denial rates by denial code and payer, days in accounts receivable by aging bucket, charge volume and reimbursement trends, and clean claim rate trends. Monthly executive reports translate these metrics into specific operational recommendations.

We Serve

Specialties We Serve

Medical billing rules, fee schedules, and documentation requirements vary dramatically by specialty.

Our certified billers specialize by clinical area - not by geography or account size:

Cardiology and Electrophysiology

Orthopedics and Sports Medicine

Physical, Occupational, and Speech Therapy

Behavioral Health and Psychiatry

Primary Care and Family Medicine

Radiology and Imaging

Oncology and Hematology

Dermatology and Plastic Surgery

Urgent Care and Emergency Medicine

Pediatrics and Adolescent Medicine

Neurology and Neurosurgery

Obstetrics and Gynecology

Payers We Work With

We manage claims across the complete US payer landscape - Medicare Part B and Part C (Medicare Advantage), Medicaid (all 50 state programs and managed Medicaid), Blue Cross Blue Shield (all regional plans), United Healthcare, Aetna, Cigna, Humana, Molina Healthcare, Centene, WellCare, and hundreds of regional and specialty payers including Workers' Compensation and No-Fault auto insurance.

Compliance

Compliance at Every Step

HIPAA Security Rule compliance for all PHI transmitted and stored in our billing operations

OIG Compliance Program policies governing billing audit and monitoring

CMS Conditions of Participation billing requirements for hospital and facility billing

Stark Law and Anti-Kickback Statute awareness in all coding and billing recommendations

Business Associate Agreement signed before any client PHI is accessed

Result

Typical Results Our Clients Achieve

Impact 1

Revenue Impact

40 % average increase in net collections

Denial rate reduced to under 5 % from industry average 15 - 25 %

Days in AR reduced by 30 to 45 days

98 % + clean claim rate on first submission

Impact 2

Operational Impact

60 % reduction in administrative billing staff time

Prior auth approval time cut by 50 %

Real - time RCM dashboard visibility

Monthly performance reporting with actionable recommendations