What the process actually is

The claim lifecycle, from the moment a patient is seen to the moment the balance closes. It is document work and system work, performed against payer rules that change constantly.

A United States medical practice bills for care after it is delivered. Between the visit and the payment sits a sequence of administrative steps, each of which can stop the money. The process your team will run is that sequence.

The ten stages
Stage	What happens	Owned by	Channel
Eligibility and benefits	Confirm the patient's active coverage, plan type, deductible position and prior-authorisation requirement before or shortly after the visit.	Provider team	Payer portal / EDI 270-271
Demographics and charge entry	Key patient and visit data and the billable services into the practice management system from the encounter documentation.	Provider team	PM system
Medical coding	Assign ICD-10-CM diagnosis codes, CPT and HCPCS Level II procedure codes and the correct modifiers from the physician's documentation.	Provider team	Encoder / PM system
Claim scrubbing	Run the claim through edit checks — payer-specific rules, NCCI edits, LCD/NCD coverage, demographic completeness — and clear every flag before release.	Provider team	Clearinghouse
Claim submission	Transmit the clean claim to the payer through the clearinghouse and confirm acceptance at both clearinghouse and payer level.	Provider team	EDI 837P / 837I
Payment posting	Post electronic remittances and scanned paper explanations of benefit; reconcile to deposits; route the patient balance correctly.	Provider team	EDI 835 / manual
Denial management	Read the denial reason and remark codes, correct the underlying defect, and file a corrected claim or a written appeal within the payer's window.	Provider team	Portal / written appeal
AR follow-up	Work the ageing bucket by bucket through payer portals — status, reprocessing requests, escalation — and record every touch against the claim.	Provider team	Payer portal (non-voice)
Credit balances	Identify overpayments and duplicate payments, evidence them and queue them for the client's refund approval.	Provider team	PM system
Reporting	Produce the daily production file, the weekly ageing movement and the monthly performance pack.	Provider team	MIS

Productivity basis

The numbers the rate was built on

Treat them as a planning basis, not a guarantee. They are the standards your team will be staffed and measured against once it is out of ramp. A seat that consistently sits below the lower bound is a training problem, not a rate problem, and will be handled as such.

Function	Daily standard per productive FTE	Accuracy floor	Turnaround
Eligibility and benefits verification	90–110 verifications	99.0%	Same business day
Demographics and charge entry	120–150 charges	99.0%	24 business hours
Coding — outpatient E&M	90–110 charts	96.0% line level	24 business hours
Coding — specialty and minor surgical	40–55 charts	96.0% line level	48 business hours
Claim scrubbing and submission	180–220 claims	99.0%	Same business day
Payment posting — electronic remittance	250–300 claims	99.0%	24 business hours
Payment posting — manual EOB	90–120 claims	99.0%	24 business hours
AR follow-up via payer portal	45–55 claims	97.0% documentation	Per ageing cycle
Denial correction and written appeal	28–35 cases	97.0%	72 business hours

Indicative monthly volume at 25 seats

At the seat mix in section 03 and 22 billing days, a 25-seat pod handles approximately:

Charge lines: 46,000
Claim submissions: 38,000
Posting transactions: 34,000
AR touches: 24,000

These figures are drawn from the client's current run-rate and are shared so that you can size supervision, quality and reporting effort honestly.

Volume is not guaranteed

Practices are acquired and lost, physicians retire, and payer mix shifts. What is contracted is the seat, not the throughput.

If sustained volume falls below the level that keeps a seat productive, Akontec will give notice and reduce the seat count rather than let you carry idle headcount at your own cost — and equally, will not ask you to absorb a volume surge without adding seats.

Ramp allowance. A new agent is not expected to hit the standard on day one. The agreed curve is 40% of standard in weeks one and two, 65% in weeks three and four, 85% in weeks five and six, and full standard from week seven. Billing begins from the day the seat is deployed to live work, not from the day the agent reaches full productivity — the ramp allowance is priced into the rate.

Next step

The productivity table is the rate.

Every figure in the commercial terms was derived from the standards above. If your floor cannot reach them at your cost base, that is better discovered now than in month four.

Read the commercial terms See the scope of work