> ## Documentation Index > Fetch the complete documentation index at: https://mso.getlemma.com/llms.txt > Use this file to discover all available pages before exploring further. # Step 9: Pick your billing stack > Choose the minimum viable combination of EHR, clearinghouse, and billing labor that can get a claim out the door and a remittance back in. Your **billing stack** is three things: an **EHR/PM system** where clinical and billing data lives, a **clearinghouse** that carries claims to payers and remittances back, and the **people** who operate both. You need all three before Step 10, and the most common launch mistake is treating the clearinghouse as an afterthought bundled into whatever the EHR sells. ## 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 ```mermaid theme={null} graph LR A[EHR / PM
clinical notes, charges,
patient ledger] --> B[Clearinghouse
scrub, translate,
route, acknowledge] B --> C[Payers] C --> B B --> D[835 remittances
back to EHR] E[Biller / RCM
the humans] -.operates.-> A E -.operates.-> B ``` If the distinction between these is fuzzy, read [Clearinghouse vs RCM vs EHR](/concepts/payments/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: 1. **Specialty fit.** A dermatology EHR has dermatology templates, biopsy tracking, and the right code sets. A generic one does not. 2. **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. 3. **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. 4. **Eligibility checking.** Integrated 270/271 at scheduling prevents more denials than anything else you can buy. 5. **Clearinghouse flexibility**, see below. 6. **Reporting.** Can you get days in AR, denial rate by CARC, and net collection rate without exporting to a spreadsheet? 7. **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. See [Choose an EHR/PM system](/guides/billing/choose-an-ehr) and the [EHR directory by segment](/reference/vendors/ehr-directory). ## 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?](/concepts/payments/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](https://www.stedi.com/healthcare) 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. Whatever you pick, verify current payer coverage for **your** specific payer mix against the vendor's published network before committing, rather than trusting any headline count. For the full four-way comparison of Stedi, Optum (Change Healthcare), Availity, and Waystar, including the 2024 Change Healthcare outage and what it revealed about concentration risk, see [The clearinghouses, compared](/reference/vendors/clearinghouse-comparison). ## Layer 3: the people Three viable shapes at launch: | Model | Cost shape | Fits when | | ---------------------------------- | ------------------------------------------------------------------- | ------------------------------------------------------------------------- | | **In-house biller** (MSO employee) | Loaded salary, roughly $55k–$95k depending on market and experience | You have enough volume to keep one busy, and you want visibility | | **Outsourced RCM** | Typically a percentage of collections | You want to start without hiring, or lack billing management capacity | | **Hybrid** | Salary + percentage | In-house front end (eligibility, charge entry), outsourced denials and AR | 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](/guides/billing/in-house-vs-outsourced-billing) and [Hire your first biller](/guides/billing/hire-a-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](/reference/legal/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 Everything else — analytics, automated eligibility, patient statements, payment plans — can come in the first 90 days. ## 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 A real visit becomes an 837. ## Sources 1. 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](https://www.quarles.com/newsroom/publications/california-cracks-down-new-laws-governing-the-corporate-practice-of-medicine-and-pe-deals). ## Related topics - [Choose an EHR/PM system](/guides/billing/choose-an-ehr.md) - [Choose a clearinghouse](/guides/billing/choose-a-clearinghouse.md) - [Decide: in-house billing vs outsourced RCM](/guides/billing/in-house-vs-outsourced-billing.md) - [What is a clearinghouse?](/concepts/payments/what-is-a-clearinghouse.md) - [Clearinghouse vs RCM vs EHR (vs biller)](/concepts/payments/clearinghouse-vs-rcm-vs-ehr.md) - [The clearinghouses, compared](/reference/vendors/clearinghouse-comparison.md) - [EHR/PM directory by segment](/reference/vendors/ehr-directory.md)