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An insurance-based practice contracts with payers and earns most revenue as adjudicated claims. It’s the default model because it’s where the patients are, but it means running a serious back office from day one.

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The revenue machine

Every dollar flows through the pipeline described in How your practice gets paid and The claim lifecycle: eligibility → visit → coding → claim → adjudication → 835/ERA → deposit → reconciliation. The setup work is front-loaded: credentialing (90-150 days per payer, start before you sign a lease), then payer setup and EFT/ERA enrollment for every plan you join.

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Choosing your panel

You don’t have to take everything. Each payer contract is a fee schedule and a compliance surface: model your expected volume by employer mix in your area, start with the 4-6 payers that cover most of it, and add (or drop) payers annually based on effective reimbursement per hour, collected dollars net of denial and rework cost, not the rack-rate fee schedule.

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Where the money leaks

Denials (CARC/RARC codes), unworked aging, underpayments against contract, and unposted paper EOBs (lockboxes exist for a reason). The fix is structural: enroll in ERA everywhere, reconcile deposits to remittances weekly, and track denial rate by payer.