How to use this checklist
Send the questions before the sales call and ask for written answers. Then use the call to check the answers against a real example. Everything that matters to you should end up in the contract or statement of work: a promise on a call is not a term. Score what you hear with the evaluation framework.
Fees
Exactly how is your fee calculated, and on what?
A good answerA written formula: the percentage or per-claim fee, and a precise definition of what counts as a collection or a claim.
Raise concern ifThe percentage applies to 'all revenue', including payments that arrive at your front desk, or 'claims' includes every resubmission.
What isn't included in that fee?
A good answerA list: setup, credentialing, old A/R cleanup, patient statements, postage, clearinghouse, reporting, each with its price or 'included'.
Raise concern if'Everything's included' with no list, or add-ons discovered after signing.
Do you charge on A/R that existed before you started?
A good answerA clear answer, and a separate, stated arrangement for legacy A/R if they work it.
Raise concern ifThe full fee applies to old balances that were going to be paid anyway.
Where do payer payments go?
A good answerStraight into your bank account; they post them but never hold your money.
Raise concern ifPayments go to their account first. For Medicare, an agent that receives payments can't be paid on a basis tied to amounts billed or collected (42 CFR 424.73(b)(3); CMS manual §30.2.4).
What can make the price change during the contract?
A good answerNamed triggers (a new location, a new specialty) and the notice they'll give.
Raise concern ifThey can change fees at will, or on renewal without notice.
Contract exit
How long is the term, does it auto-renew, and what notice ends it?
A good answerA stated term, renewal and notice period you can live with, and termination for cause if they don't perform.
Raise concern ifMulti-year auto-renewal with a narrow notice window and no exit for poor performance.
What does it cost to leave?
A good answerNo termination fee, or a stated one that reduces over time.
Raise concern ifA fee equal to months of service, or fees to release your data.
After we leave, who works the claims already submitted?
A good answerA written run-out plan: how long they keep working them, what you pay, and the hand-off to your next biller.
Raise concern ifWork stops on the termination date, or they keep charging on everything collected for months.
Data ownership
Who owns our billing data and reports?
A good answerYou do, in the contract's words.
Raise concern ifThe contract is silent, or grants them rights to use your data beyond serving you.
If we leave, what do we get back, in what format and how fast?
A good answerA full export (claims, payments, denials, notes, patient balances) in a standard format within a set number of days, at no charge.
Raise concern ifPDF reports only, a fee for export, or 'we'll work something out'.
Will we keep access to our data while we're with you?
A good answerLive access to your own claims and reports, any time.
Raise concern ifYou see only what they send you each month.
How long do you keep our records after we leave?
A good answerA stated retention period that meets your obligations, then documented destruction or return. For example, Medicare requires 7 years' documentation for ordered, referred or prescribed services (42 CFR 424.516(f)).
Raise concern ifNo answer, or records deleted at termination before you have them.
Denial handling
Walk us through a denial you worked last week for a practice like ours.
A good answerA specific story: the reason code, who saw it, how fast, the fix, and how the cause was prevented next time.
Raise concern ifA general description of 'our proven process' with no example.
How quickly is a denial worked, and when do you appeal?
A good answerA stated working time and appeal criteria, with tracking of each payer's appeal and filing deadlines (Medicare: 42 CFR 424.44).
Raise concern ifLow-value denials are written off without telling you, or there's no rule for when to appeal.
How do you report denials to us?
A good answerInitial and final denial rates by payer and reason code (CARCs), with written definitions.
Raise concern ifOne 'denial rate' with no definition, or none at all.
Do you guarantee a denial rate or a collection increase?
A good answerNo guarantee, but their measured results for comparable practices, with the definitions behind them.
Raise concern ifA guaranteed number. Results depend on your payers, specialty and documentation; a guarantee without definitions can't be checked.
Who writes off a balance, and does that need our approval?
A good answerWrite-offs above a set amount need your sign-off, and all are reported.
Raise concern ifThey decide alone and you find out from the aging report.
HIPAA and security
Will you sign our business associate agreement?
A good answerYes, or they provide one that covers HHS's sample provisions.
Raise concern ifHesitation. A billing company is a business associate (HHS).
Who can see our patients' information, and from where?
A good answerNamed roles, access controls, audit logs and a list of subcontractors with their own BAAs.
Raise concern ifThey can't say who has access, or subcontract work without telling you.
How will you tell us about a breach?
A good answerA stated process and timeline in the BAA.
Raise concern if'It won't happen.'
Scope and staffing
Do you do coding, or bill from the codes we send?
A good answerA clear answer either way. Coding is a separate discipline; if they code, ask about credentials and audits.
Raise concern ifThey change codes without telling you, or imply coding is included when it isn't.
Who is our contact, and who works our claims?
A good answerA named person, their workload, and a coverage plan for absences and turnover.
Raise concern ifA shared support inbox and no named owner.
Which current clients use our EHR and our specialty, and can we call one?
A good answerA reference you can call.
Raise concern ifNo reference on your system or in your specialty.
Questions people ask
What should be in a medical billing contract?
Scope, fee formula and definitions, term and renewal, termination and run-out, data ownership and export, reporting, payment routing, and a business associate agreement. If a promise matters to you, it belongs in one of those.
Can a billing company keep my data after I cancel?
Only as the contract and BAA allow. Make sure both say you own the data, how it's returned, and when it's destroyed.
Is a guaranteed collection rate a good sign?
Not on its own. Ask what it's measured against and how; without definitions, a guarantee can't be checked. See benchmarks.
Sources
Every figure and rule on this page links to the organization that produced it. Check the source before you rely on it: payer and federal rules change.
- 42 CFR 424.73: Prohibition of assignment of claims by providers (billing agent conditions, paragraph (b)(3)) · Electronic Code of Federal Regulations
- Medicare Claims Processing Manual, Chapter 1 (§30.2.4 Payment to Agent; §80.2 clean claims and interest) · Centers for Medicare & Medicaid Services
- 42 CFR 424.516(f): documentation retention for ordered, certified, referred or prescribed services · Electronic Code of Federal Regulations
- 42 CFR 424.44: Time limits for filing claims · Electronic Code of Federal Regulations
- Claim Adjustment Reason Codes · X12
- Business Associates (HIPAA guidance and FAQs) · U.S. Department of Health & Human Services, Office for Civil Rights
- Sample Business Associate Agreement Provisions · U.S. Department of Health & Human Services
- Altair Health · altair-health.com
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