What Meridian did
Meridian chose a dermatology-capable cloud EHR, connected it to Stedi as the clearinghouse via API rather than using the EHR’s default embedded option, and hired one experienced biller as an MSO employee. Alex made the clearinghouse a deliberate decision because Meridian intends to build its own eligibility and denial-analytics tooling, and wanted claim and remittance data available programmatically rather than trapped in a vendor portal.The three layers
If the distinction between these is fuzzy, read Clearinghouse vs RCM vs EHR before choosing anything. Buying the wrong layer to solve a problem in another layer is the single most expensive mistake in this step.Layer 1: EHR / practice management
The EHR holds the clinical record; the PM side holds demographics, insurance, charges, the patient ledger, and claim status. Most systems for small groups combine them. What to weigh, in order:- Specialty fit. A dermatology EHR has dermatology templates, biopsy tracking, and the right code sets. A generic one does not.
- Data export rights. Read the contract. You will want your data later, for analytics, for a migration, for diligence. Some vendors charge thousands to export what is already yours.
- ERA auto-posting quality. This determines how many hours a week your biller spends on manual posting. Ask for a demo using a real 835 with a takeback in it.
- Eligibility checking. Integrated 270/271 at scheduling prevents more denials than anything else you can buy.
- Clearinghouse flexibility, see below.
- Reporting. Can you get days in AR, denial rate by CARC, and net collection rate without exporting to a spreadsheet?
- Pricing model. Per provider per month, percentage of collections, or per encounter. Percentage-of-collections pricing from a software vendor deserves scrutiny.
🦷 Dental, Open Dental, Dentrix, Eaglesoft, Curve, and Archy dominate. Claims are 837D with CDT codes; make sure the clearinghouse handles dental.
🧠 Behavioral health, SimplePractice and TherapyNotes are the small-group defaults. Check how they handle supervision billing and 42 C.F.R. Part 2 confidentiality.
🦴 PT/Chiro, WebPT and Prompt are built around visit volume and plan-of-care certification tracking, which generic EHRs handle badly.
Layer 2: the clearinghouse
A clearinghouse translates your claim into the X12 837 format each payer expects, validates it against payer-specific edits, routes it, and brings back acknowledgments (999, 277CA) and remittances (835). See What is a clearinghouse?.Do you even get a choice?
Sometimes not. Many EHRs embed a clearinghouse and make switching hard or impossible. Ask before you sign the EHR contract, because it is much easier to choose an EHR that permits your clearinghouse than to change clearinghouses later.What matters at this step
Two questions carry disproportionate weight when picking a clearinghouse at launch:- Do you need API access? If you plan to build your own eligibility, denial, or AR analytics, or if you are a healthtech company operating an MSO-PC structure, you need a vendor that exposes eligibility, claims, claim status, acknowledgments, and 835 retrieval over a modern API. Newer API-first vendors like Stedi sit at one end of this spectrum; legacy clearinghouses with bolt-on APIs sit at the other. Meridian picked Stedi for this reason.
- Do you need bundled RCM tooling? If you want denial worklists, patient statements, and analytics dashboards from the same vendor, a platform like Waystar is a different proposition. Optum and Availity sit between these poles with the largest installed bases and payer connectivity.
Layer 3: the people
Three viable shapes at launch:
At Meridian’s launch volume, one in-house biller was the right call, but the honest general answer is that below roughly two full-time clinicians, an outsourced service is usually cheaper than a competent full-time hire. See In-house billing vs outsourced RCM and Hire your first biller.
Billing staff are MSO employees; billing decisions belong to the PC. The MSO can provide billing support, staff, and systems. It should not be directing what diagnosis or procedure codes get assigned — that is clinical judgment, and California’s SB 351 explicitly names billing and coding among the functions a management entity may not control.1 Document in the MSA that coding is the PC’s responsibility, with the MSO providing personnel and systems. See MSA clause anatomy.
Minimum viable stack
To submit one claim you need, at minimum:- An EHR/PM that can produce a charge with CPT, ICD-10, POS, and provider identifiers
- A clearinghouse connection with EDI enrollment complete for your payer
- ERA delivery configured to that clearinghouse
- One person who knows how to read a 277CA rejection
Your artifact from this step
- Signed EHR contract, with export rights confirmed in writing
- Clearinghouse selected and connected, with submitter ID issued
- EDI enrollment submitted for your first payer
- ERA delivery pointed at the correct receiver
- Billing labor in place, with the coding-responsibility question settled in the MSA
Checklist
- EHR chosen on specialty fit and data portability
- Confirmed whether the EHR permits your choice of clearinghouse, before signing
- Clearinghouse selected; payer coverage verified for your actual payer mix
- Submitter/receiver IDs issued and recorded
- EDI and ERA enrollment submitted for payer #1
- Billing labor model decided and staffed
- MSA reflects that coding responsibility sits with the PC
Next
Step 10: Submit your first claim
A real visit becomes an 837.
Sources
- Cal. S.B. 351 (2025), effective January 1, 2026. Summary: Quarles, California Cracks Down: New Laws Governing the Corporate Practice of Medicine and PE Deals.