Pediatric Billing Services From 5.5%: VFC & Medicaid

Who our pediatric billing service is for

Our pediatric billing service is built for independent pediatric practices, from a solo pediatrician to groups of 6–15 clinicians. Most bill Medicaid managed care, separate CHIP plans and commercial insurance, stock both VFC and private vaccine, and bill newborn care.

Hand your billing to us when:

• the biller who knew your state's vaccine modifiers has left, and administration lines come back;
• Medicaid and CHIP claims sit unworked while short filing windows run out;
• newborn claims wait for the baby's own Medicaid number instead of going out;
• screening lines come back bundled or denied, and no one has time to appeal them.

What we take over and what your practice keeps

We take over pediatric billing from the coverage check to the posted payment and the family statement. We check every code against your clinician's documentation and never change a code without the clinician's sign-off. Every checkup, sick visit and screening line passes our coding review against the signed note, and our coverage checks run for new patients and changed coverage. Your pediatricians keep examining, counseling families and signing notes; the figure shows a month of our pediatric billing.

Read the workflow as text

1. Check coverage and VFC — Plan checked for new patients and changed coverage; VFC status taken from check-in. Owner: Our team, your desk.
2. Check codes on the note — Checkup, any same-day sick visit and each screen checked against the signed note. Owner: Your pediatricians sign.
3. Match vaccine lines — Each vaccine paired with its administration units and the state's stock modifier. Owner: Our billing team.
4. Submit clean claims — Claims with complete charge data go out within 1 business day. Owner: Our billing team.
5. Post and work denials — Bundled screens, cut sick visits and unit denials worked within 2 business days. Owner: Our billing team.
6. Monthly KPI report — Vaccine, screening, newborn and Medicaid deadline measures, each defined in writing. Owner: Sent to you.

Where pediatric practices lose revenue, and what we do about it

Pediatric revenue leaks where a checkup, a vaccine and a state program rule meet on one date of service.

How we handle checkups, sick visits and screenings

• A sick visit lost inside the checkup. We compare the separately documented problem with the preventive note before billing a sick visit on the same day.
• Screens past their frequency limit. We check the screening history and scored tool before billing, and our denial management team works an unsupported bundling adjustment against the plan's policy.

How we handle vaccine, VFC and newborn claims

• Waived VFC fees billed to families. We leave administration fees your practice waived off family statements and keep VFC vaccine cost out of those balances.
• CHIP members recorded as VFC-eligible. We use the coverage and VFC status your front desk records to distinguish program vaccine from private stock before building the claim.
• Newborn claims held for the baby's ID. We confirm the state's permitted newborn identifier route and track the transition to the baby's own ID, so a missing permanent number does not become an unexplained hold.

Our timely filing guide shows which payers, some state Medicaid programs among them, give your practice the least time to file. The Free A/R Deadline Map sorts your unpaid Medicaid, CHIP and commercial claims over 90 days by the deadline each one faces, in 5 business days. Clock starts with your claim-level aging export and signed BAA; above 10 requests in a week, we confirm your date within 1 business day.

What our pediatric billing costs

Pediatric practices sit in our Primary care, pediatrics & urgent care row, and the rate steps down as the number of billing clinicians grows. Nurse practitioners who bill under their own NPIs count toward the size band. Your fee is a percentage of insurance payments posted on claims we submitted or worked, net of payer recoupments and refunds. We take 0% of patient payments, copays and anything your front desk collects. Setup is $0. Invoices 1–3: only percentage fees on that month's insurance payments, plus any statements or add-ons you order. Percentage fees and mailed statements are capped at 9.0% of that month's insurance payments; from invoice 4, the $400 minimum applies even in a month when the cap comes to less. Add-ons are on our published rate card.

How we start: switching from in-house or another billing company

A handover puts open Medicaid and CHIP claims at risk when their plan-specific filing windows are not carried forward. We start with six things from you:

1. The signed service agreement and business associate agreement (BAA).
2. Logins to your practice-management system and clearinghouse.
3. A claim-level aging report with Medicaid, CHIP and managed care claims flagged, which we sort by deadline.
4. Your VFC provider details and the vaccine stock modifiers your state uses.
5. A list of newborns still billed under a mother's Medicaid ID.
6. A kickoff call with your front desk and billing lead.

Go-live, when your first claims go out, comes within 5 business days of access; any unbilled backlog follows within 10 business days of access. Clock starts with your signed agreement, signed BAA and working system logins; it extends day for day while we wait on access. Every inherited claim within 30 days of a filing, corrected-claim or appeal deadline is worked within 5 business days of access. Starts at access; covers up to 250 claims (more gets a day-1 deadline schedule); worked means submitted, corrected, appealed or returned with the fix.

Our handoff guide for changing billing companies names the files to request from your outgoing company. Questions first? Talk to our billing team.

What we report each month, and the guarantees that back it

On-Our-Watch Guarantee. If a claim misses a filing, corrected-claim or appeal deadline while it is on our watch, we pay you what it would have paid. Claims we get complete 10+ business days before the deadline; contracted rate less any copay you collected, paid automatically within 30 days of final denial; capped $10,000/month; your holds excluded.

Clock-or-Credit Guarantee. From go-live, every new claim goes out within 1 business day of complete charge data, and every denial is worked within 2 business days of posting — or $25 comes off your invoice for each late one. Mon–Fri ET business days by your system's timestamps; worked: resubmitted, appealed or returned with the fix; auto-credited; capped at monthly fee; clearinghouse outages excluded.

Our service standards, measured on pediatric claims

You can check each standard against your own system's timestamps. The monthly report defines clean claims, A/R days and net collection rate in writing, plus four pediatric measures:

• Vaccine administration denial share: denied ÷ billed administration lines.
• Screening lines paid on their own: paid screening lines ÷ screening lines billed, by payer.
• Newborn claims under a mother's ID: open claims still on the mother's ID, with days since service.
• Medicaid claims near their limit: unpaid Medicaid and CHIP claims within 30 days of their filing limit.

We publish client results only with written permission. Until we have them, judge us by the guarantees and the free Deadline Map.

Your systems, new pediatricians and Medicaid plan enrollment

We bill inside your own practice-management system and clearinghouse; the systems page lists the access we need. No one on our team opens patient data before your BAA is signed.

When a new pediatrician or nurse practitioner joins, our Medicaid and MCO enrollment service files their enrollment with each Medicaid program and managed care plan you choose. Included, New-Clinician Enrollment: Clinicians who join while you're a client get enrollment filed with up to 5 payers each (the payer decides), with no per-payer fee. Enrollment beyond that costs $149 per payer through Credentialing & Payer Enrollment. Billed only after the payer confirms your effective date; $0 if denied or panel closed; filed within 5 business days of your complete packet.

Common questions

How much do your pediatric billing services cost?

From 6.5% for a solo pediatrician down to 5.5% for a group of 6–15 clinicians, of insurance payments, with 0% of family payments and $0 setup. Our medical billing pricing page shows the minimum, cap and add-ons.

Is there a long-term contract or a cancellation fee?

No. Leave with 30 days' notice and no termination fee. Want a run-out? We keep working the claims we submitted for 90 days at your plan rate. Decline it and we charge nothing on payments that post after you leave. Notice by email; optional run-out covers claims we submitted before your exit date, at your plan rate; handover file within 10 business days of exit.

How fast can you take over our pediatric claims?

Go-live, when your first claims go out, comes within 5 business days of access; any unbilled backlog follows within 10 business days of access. Clock starts with your signed agreement, signed BAA and working system logins; it extends day for day while we wait on access. The clock and the six things we need from your practice are under how we start.

Do you bill VFC vaccine administration as well as private-stock vaccines?

Yes. We distinguish VFC stock from private stock and check the administration units and stock reporting your payer requires. We do not charge families for VFC vaccine, consistent with CDC provider guidance; waived administration fees stay off their statements.

Do you bill same-day sick visits with our well-child checkups?

Yes, when your pediatrician's note names a separate problem and supports the level billed. Where the payer requires modifier 25, we check it is on the line, and any code change goes to your pediatrician for sign-off. We then check the payment against that payer's own policy.

Can you handle newborn claims before the baby has its own Medicaid ID?

Yes. When the mother had full Medicaid in your state at the birth, we bill newborn care under her ID, as 42 CFR 435.117 allows, and switch to the baby's own number once issued. The delivery goes on the mother's claim, billed by our OB-GYN billing team.

Which EHR and practice-management systems do you work in?

We work inside your existing practice-management system and clearinghouse; tell us which ones and we confirm in writing within 1 business day. Our EHR compatibility page lists the access we need.

Can you enroll a new pediatrician or nurse practitioner with our Medicaid plans?

Yes. Clinicians who join while you are a client are covered by New-Clinician Enrollment. Its payer limit, the per-payer fee beyond it and the terms are in the enrollment section.