Medical Billing Services in Massachusetts
Massachusetts runs Medicaid through a model most states do not use: accountable care organizations, managed care organizations, and a primary care clinician plan, side by side. For a practice, that means the member’s plan type changes how the claim is built, and in an accountable care organization, membership follows the member’s primary care provider. Billing MassHealth like a standard managed care program is how claims go wrong here.
MedPlus RCM provides medical billing, coding, credentialing, and denial management for Massachusetts practices of every specialty, built around the state’s actual payers and programs.
Massachusetts’s payer landscape
Massachusetts Medicaid is MassHealth, delivered through three managed care paths: accountable care organizations (ACOs), managed care organizations (MCOs), and the Primary Care Clinician (PCC) plan. MCO coverage includes WellSense Essential and Tufts Health Together, while ACO partnerships include Fallon Health, Tufts Health Together, and WellSense. In an ACO, the member’s coverage is tied to their primary care provider, so eligibility and primary care assignment both have to be confirmed before the visit. A member who switched primary care providers may sit in a different plan than the last claim suggests.
Commercial coverage runs through Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim Health Care, Tufts Health Plan, Fallon Health, Health New England, Mass General Brigham Health Plan, and UnitedHealthcare. The same carriers appear across both the commercial market and MassHealth partnerships, so a practice has to keep the member’s line of business straight: a commercial Tufts claim and a MassHealth Tufts claim do not follow the same rules.
What MedPlus RCM handles for Massachusetts practices
- End-to-end medical billing. Charge entry, claim scrubbing, submission, payment posting, and patient billing, the full cycle.
- Medical coding. Certified coders assign current ICD-10, CPT, and HCPCS codes matched to your documentation and specialty.
- Provider credentialing and enrollment. End-to-end enrollment with MassHealth plans, commercial payers, and Medicare, plus re-credentialing maintenance.
- Denial management and recovery. Every denial investigated to root cause, corrected, and appealed with documentation.
- A/R recovery. Aged and outstanding balances audited and pursued, including balances already written off where the appeal window is still open.
- Financial reporting. Clean claim rates, collections, denial patterns, and A/R aging visible by payer and provider.
We serve practices statewide, Boston, Worcester, Springfield, Cambridge, Lowell, and New Bedford, across specialties including primary care, mental and behavioral health, cardiology, orthopedics, dermatology, and physical therapy.
Results Massachusetts practices can check
MedPlus RCM maintains a 99% clean claim rate and keeps client accounts receivable under 30 days. Pricing is a performance-based percentage of successfully collected revenue: if you don’t get paid, we don’t get paid. We are 100% HIPAA compliant, and onboarding takes 2 to 4 weeks depending on practice size, with no disruption to your daily cash flow.
Frequently asked questions
What is a MassHealth ACO, and why does it change billing?
An accountable care organization is a group of providers that coordinates a member’s care, and membership follows the member’s primary care provider. If the member changed primary care providers, their plan may have changed too, so eligibility and assignment must be checked before the visit.
Do you work with MassHealth MCOs and ACOs?
Yes. We bill WellSense, Tufts Health Together, Fallon Health partnerships, and the PCC plan, as well as commercial and Medicare plans.
How long does it take to switch our billing to MedPlus RCM?
Onboarding takes between 2 and 4 weeks depending on practice size, including data migration and payer clearinghouse setup.
What does MedPlus RCM charge?
A performance-based percentage of successfully collected revenue. If you don’t get paid, we don’t get paid.
Get a free financial audit
Find out where your Massachusetts practice is losing revenue. Request a free financial audit and our specialists will review your claims, denials, and A/R.
