MedStats Billing delivers end-to-end revenue cycle management built for Virginia practices. We hold carriers to the 40-day clean claim standard in § 38.2-3407.15, claim the interest Virginia law says must be paid without demand, block recoupments that reach back more than 12 months, and bill all five Cardinal Care Managed Care plans alongside work injury claims priced to the correct medical community fee schedule.
Virginia is a deadline-and-recoupment state. Commercial carriers work to a 40-day clean claim clock and owe interest without the provider ever asking for it, and the same statute caps how far back a carrier may claw money out of a paid claim. Work injury care runs on a separate 45-day objection and 60-day payment rule with a one-year window to take the dispute to the Commission. Medicaid moved five plans onto one Cardinal Care contract and replaced Molina with Humana in July 2025. Most Virginia revenue leaks are calendar failures, not coding failures.
Virginia Billing Specializations:
Ethics and Fairness in Carrier Business Practices (§ 38.2-3407.15) — Every provider contract must require the carrier to pay a clean claim within 40 days of receipt and to request any additional information within 30 days. We calendar both dates and escalate to the Bureau of Insurance where the standard is breached.
Interest Without Demand — Interest owing on a claim under § 38.2-3407.1 or § 38.2-4306.1 must be paid without necessity of demand, at the time the claim is paid or within 60 days after. Because no one has to ask for it, almost nobody checks that it arrived. We do.
The 12-Month Recoupment Limit — A carrier may not retroactively deny a previously paid claim, or offset it against future payments, beyond 12 months after payment except in defined circumstances such as fraud. We date-check every recoupment before it reduces your remittance.
Electronic Notification (from 1 January 2026) — All notifications and information a carrier is required to give under the fair business standards must now be delivered electronically, which makes the carrier’s own timeline auditable. We keep that trail.
Cardinal Care Managed Care — Five plans hold the unified Cardinal Care contract: Aetna Better Health of Virginia, Anthem HealthKeepers Plus, Humana Healthy Horizons in Virginia, Sentara Health Plans and UnitedHealthcare Community Plan. Molina exited on 1 July 2025 and its members moved to Humana, so plan assignment must be verified before the visit.
Workers’ Compensation Prompt Payment (§§ 65.2-601, 65.2-605.1) — An uncontested itemization must be paid in full within 60 days of receipt, and an employer or carrier contesting, denying or deeming a bill incomplete must notify the provider within 45 days with the reasons, the information required and the provider’s remedies. Interest attaches when either deadline is missed.
Workers’ Compensation Fee Schedules (§ 65.2-605) — Absent a contract, payment is the lesser of the billed amount or the Virginia fee schedule amount in effect on the date of service, set by six medical communities across the Commonwealth. Provider claims to the Commission carry a one-year limitation.
Balance Billing Protection — Virginia’s balance billing law routes out-of-network emergency care and ancillary services at in-network facilities into a commercial arbitration process rather than the patient’s statement. We prepare the payment data those disputes turn on.
Major Virginia Payers — Anthem Blue Cross and Blue Shield of Virginia, Sentara Health Plans, Aetna, Cigna, UnitedHealthcare, Piedmont Community HealthCare and TRICARE denial workflows.
Built to bring clarity, control and consistency to your Virginia practice’s revenue cycle.
MedStats Billing manages the complete revenue cycle for Virginia providers — from Medicaid provider enrollment and Cardinal Care plan credentialing, through coding, claim scrubbing and submission, to denial resolution, interest and recoupment audits, and workers’ compensation payment claims before the Virginia Workers’ Compensation Commission.
Certified CPT, ICD-10-CM, and HCPCS coding with pre-submission claim scrubbing built around each payer's edits, so claims pay on the first pass. We manage charge entry, claim submission, payment posting, and insurance follow-up.
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Enrollment with Medicaid managed care plans, Medicare via PECOS, and commercial payers — plus CAQH maintenance and re-credentialing deadline tracking, so your providers stay in-network and billable without gaps.
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Coverage confirmed before the visit — active policy status, deductibles, co-pays, plan type, and prior authorization requirements — so front-end denials are caught while there is still time to fix them.
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Aged claims worked by payer and denial reason, with appeals filed inside each plan's window. We monitor outstanding balances, manage rejections, and drive down days in A/R to protect cash flow.
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A detailed review of coding accuracy, documentation standards, and denial patterns that identifies revenue leakage and compliance exposure — before a payer audit finds it for you.
Explore serviceLocal SEO, Google Business Profile optimization, and reputation management built for medical practices — helping the patients already searching for your specialty find you first.
Explore serviceVirginia practices lose more revenue to missed calendars and unchallenged takebacks than to coding, and three of the four leaks below are money the payer already owes or has taken improperly. These are the four we eliminate:
Interest on a late claim must be paid without necessity of demand, at the time the claim is paid or within 60 days after. Because the provider is not required to ask, practices assume it was included. It usually was not, and nobody reconciles the remittance to find out.
A carrier may not retroactively deny a previously paid claim, or set it off against current payments, more than 12 months after payment except in defined circumstances. Offsets arrive buried in a remittance and get absorbed. We date-check each one and push back on the ones the statute bars.
An employer or carrier that contests, denies or treats a work injury itemization as incomplete must say so within 45 days, with reasons and the remedies available; an uncontested bill must be paid in full within 60 days. Practices that do not track those two dates lose both the interest and, after a year, the claim itself.
Virginia sets work injury maximums by six medical communities, and absent a contract payment is the lesser of the billed amount or the schedule in effect on the date of service. Practices that bill from a neighbouring region’s figures, or from a superseded schedule, invite a reduction they cannot dispute.
Every carrier provider contract must require payment of a clean claim within 40 days of receipt, with any request for additional information made within 30 days of receipt. Interest owed under § 38.2-3407.1 or § 38.2-4306.1 is payable without necessity of demand at the time of payment or within 60 days after, and from 1 January 2026 the carrier’s required notifications must be delivered electronically.
A retroactive denial is any attempt to collect back a payment already made, whether by reducing current payments, withholding future ones or any other offset. Those denials are barred beyond 12 months after payment except in defined circumstances such as fraud, which gives providers a real defence against silent takebacks.
An uncontested itemization must be paid in full within 60 days of receipt, and a contest, denial or incompleteness notice must reach the provider within 45 days with reasons, required information and available remedies. Absent a contract, payment is the lesser of the billed amount or the Virginia fee schedule for the applicable medical community, and provider claims to the Commission carry a one-year limitation.
Virginia merged Medallion 4.0 and CCC Plus into one Cardinal Care Managed Care programme in October 2023, and five plans now hold the contract: Aetna Better Health of Virginia, Anthem HealthKeepers Plus, Humana Healthy Horizons in Virginia, Sentara Health Plans and UnitedHealthcare Community Plan. Molina left on 1 July 2025 and its members were moved to Humana, so eligibility and plan assignment are verified per visit.
MedStats Billing provides tailored billing solutions for a wide range of medical specialties, ensuring accurate coding, fewer denials, and faster reimbursementsto maximizes your revenue potential.
MedStats Billing handles Medicaid enrollment, Cardinal Care plan credentialing, 40-day clean claim tracking, interest and recoupment audits and workers’ compensation payment claims across Virginia, giving practices end-to-end RCM support in a state where the calendar decides who keeps the money.
Claims are scrubbed against Cardinal Care plan and commercial carrier edits before submission to drive clean first-pass reimbursement.
Every offset and retroactive denial is dated against the 12-month limit before it is allowed to reduce a remittance, and the ones the statute bars are challenged rather than absorbed.
We reconcile the 40-day clock on every clean claim and pursue the interest Virginia law says is payable without demand, rather than assuming the carrier added it.
Working knowledge of Anthem Blue Cross and Blue Shield of Virginia, Sentara Health Plans, Aetna, Cigna, UnitedHealthcare, TRICARE and the five Cardinal Care Managed Care plans.
Whether you practise in Richmond, Virginia Beach, Arlington, Roanoke or Charlottesville, our workflows adjust seamlessly as your group grows across the Commonwealth.
HIPAA-compliant data handling and controlled access protect patient health information and billing records at every stage.
We integrate smoothly with widely used EHR platforms to ensure accurate data flow from documentation to claim submission. This reduces manual errors, speeds processing, and supports cleaner reimbursements.
We work alongside leading systems including:
Schedule a complimentary billing assessment with MedStats Billing to uncover hidden revenue loss, audit the recoupments carriers have taken out of your remittances, and quantify the interest your practice is owed on claims paid outside the 40-day standard.
Under § 38.2-3407.15 every provider contract must require the carrier to pay a clean claim within 40 days of receipt, and to request any additional information needed within 30 days of receipt. Interest owing under § 38.2-3407.1 or § 38.2-4306.1 must be paid without necessity of demand, either at the time the claim is paid or within 60 days after. Beginning no later than 1 January 2026, the notifications the carrier owes the provider must be delivered electronically.
Not more than 12 months after the date of payment, except in defined circumstances such as fraud or other legal action. A retroactive denial includes any attempt to collect back money already paid, whether by reducing other payments currently owed, withholding or setting off against future payments, or otherwise reducing your claim payments. Every offset should be dated before it is accepted.
Five plans hold the Cardinal Care Managed Care contract: Aetna Better Health of Virginia, Anthem HealthKeepers Plus, Humana Healthy Horizons in Virginia, Sentara Health Plans and UnitedHealthcare Community Plan. Cardinal Care Managed Care merged the former Medallion 4.0 and CCC Plus programmes in October 2023, and Molina Healthcare left the programme on 1 July 2025 with its members moved to Humana.
Verify the current plan before the visit rather than relying on the card on file, because former Molina members were moved to Humana Healthy Horizons with an effective date of 1 July 2025 unless they actively chose another plan. Confirm authorizations with the receiving plan, since approvals issued by the exiting plan do not carry forward indefinitely.
Payment for health care services the employer or carrier does not contest, deny or consider incomplete must be made in full within 60 days after receipt of each separate itemization. Where the bill is contested, denied or treated as incomplete, the payer must notify the provider within 45 days, stating the reasons, any additional information required and the remedies available to the provider. Interest attaches when those deadlines are missed.
Under § 65.2-605, where there is no contract setting the price, payment is the lesser of the billed amount or the amount in the applicable Virginia fee schedule in effect on the date the service was provided. Maximums are set for six medical communities across the Commonwealth, defined by ZIP code prefix, and the Commission updates them periodically. A provider claim for payment must reach the Commission inside the one-year limitation in § 65.2-605.1.
We serve practices and healthcare facilities across all six medical communities, including Virginia Beach, Chesapeake, Norfolk, Richmond, Arlington, Alexandria, Newport News, Hampton, Roanoke, Portsmouth, Suffolk, Lynchburg, Charlottesville, Harrisonburg and Fredericksburg.
