Medical Billing Terms of Service

Agreement to Terms

Welcome to ClainetRCM. These Terms of Service ("Terms") constitute a legally binding agreement between you (the "Client," "you," or "your") and ClainetRCM ("we," "us," or "our") governing your use of our revenue cycle management services and platform.

These Terms apply to healthcare organizations, clinics, solo practices, and healthcare providers who engage ClainetRCM for revenue cycle management and provider enrollment services.

Service Description

ClainetRCM provides comprehensive revenue cycle management services directly to healthcare providers, including but not limited to:

Core Services

• Claims Management: Submission, tracking, and follow-up of insurance claims
• Payment Posting: Recording and reconciliation of payments from insurance companies and patients
• Denial Management: Analysis, appeal, and resolution of denied or rejected claims
• Eligibility Verification: Patient insurance verification and benefits confirmation
• Prior Authorization: Obtaining necessary approvals from insurance payers
• Provider Enrollment: Credentialing and enrollment with insurance networks
• Account Receivables Management: Collection and follow-up on outstanding balances
• Reporting and Analytics: Financial reporting and performance analysis

Service Delivery Model

ClainetRCM operates as an independent organization and provides services directly without third-party vendor involvement. We communicate directly with insurance companies and healthcare providers on your behalf to fulfill our revenue cycle management obligations.

Client Responsibilities

To enable ClainetRCM to provide effective services, you agree to:

Fees and Payment Terms

Service Fees

ClainetRCM's fees are set out in the service agreement executed between the parties. Our standard structure is:

• A percentage of collections, calculated on amounts actually received for claims we worked. Starting at 2.29% of monthly collections; your exact rate is stated in your agreement and does not change without your written consent.
• No setup or implementation fee. Onboarding is included.
• No monthly minimum. If we collect nothing in a month, no collections fee is due for that month.
• Flat fees for fixed-scope work such as provider credentialing, quoted per provider per payer in writing before the work begins.
• Hourly fees for scribing and virtual assistant services, at the rate stated in your agreement.

Aged accounts receivable that predates your engagement with us is quoted separately, and we will tell you before starting if a batch of old claims is unlikely to be collectible.

Payment Terms

• Fees are invoiced monthly based on the agreed-upon payment structure
• Payment is due within 30 days of invoice date unless otherwise specified
• Late payments may incur interest charges at the rate of 1.5% per month or the maximum allowed by law
• ClainetRCM reserves the right to suspend services for accounts more than 60 days past due

Term and Termination

Service Term

Service begins on the effective date in your service agreement and continues month to month. There is no fixed minimum term and no automatic lock-in period.

Termination by Client

• You may terminate at any time by giving 30-day notice to cancel in writing.
• You remain responsible for fees on collections received through the termination date.
• There is no early-termination penalty.
• We continue working your open claims through the notice period rather than downing tools.
• On termination we return your records, open claim data and payer portal access at no charge.

Termination by ClainetRCM

We may terminate services under the following circumstances:

• Non-payment of fees for more than 60 days
• Material breach of these Terms or your service agreement
• Loss of required licenses or credentials by your organization
• Engagement in fraudulent or illegal billing practices
• Failure to provide necessary information or cooperation despite reasonable requests

Transition Upon Termination

Data Ownership and Use

Client Data Ownership

You retain all ownership rights to your patient data, clinical information, and business records. ClainetRCM acts as a business associate under HIPAA and processes your data solely to provide our services.

ClainetRCM's Use of Data

We use your data exclusively for:

• Providing revenue cycle management services to your organization
• Communicating with insurance companies and healthcare providers on your behalf
• Generating reports and analytics for your organization
• Maintaining compliance with legal and regulatory requirements
• Improving our internal processes and service quality (using de-identified, aggregated data only)

Data Security and Privacy

ClainetRCM maintains comprehensive security measures to protect your data. Please refer to our Privacy Policy for detailed information about our data handling practices, security measures, and compliance with HIPAA regulations.

Confidentiality

Both parties agree to maintain the confidentiality of all proprietary and confidential information disclosed during the course of our relationship, including:

• Patient health information and personal data
• Financial information and billing data
• Business practices, strategies, and processes
• Proprietary software, systems, and methodologies
• Terms of the service agreement and pricing information

Confidential information may only be disclosed as required by law or with prior written consent from the disclosing party.

HIPAA and Regulatory Compliance

Business Associate Agreement

ClainetRCM acts as your Business Associate under the Health Insurance Portability and Accountability Act (HIPAA). A separate Business Associate Agreement (BAA) is executed alongside these Terms, establishing our obligations regarding Protected Health Information (PHI).

Compliance Obligations

Client's Compliance Obligations

You represent and warrant that:

• All services billed are medically necessary and properly documented
• You maintain compliance with applicable licensing and certification requirements
• You have proper authorizations to disclose PHI to ClainetRCM
• You comply with all federal and state healthcare laws and regulations

Representations and Warranties

ClainetRCM's Warranties

ClainetRCM represents and warrants that:

• We will perform services in a professional and workmanlike manner
• Our staff possesses the necessary skills and qualifications to provide our services
• We maintain appropriate systems, security measures, and business practices
• We comply with all applicable laws and regulations governing our operations
• We maintain appropriate insurance coverage for our operations

Client's Warranties

You represent and warrant that:

• You have the authority to enter into this agreement and engage our services
• All information provided to ClainetRCM is accurate and complete
• You maintain all required licenses, credentials, and certifications
• Services billed comply with applicable medical necessity and documentation standards
• You have obtained necessary patient authorizations and consents

Disclaimer of Warranties

Limitation of Liability

Liability Cap

To the maximum extent permitted by law, ClainetRCM's total liability for any claims arising from or related to our services shall not exceed the fees paid by you to ClainetRCM during the twelve (12) months preceding the claim.

Excluded Damages

IN NO EVENT SHALL CLAINETRCM BE LIABLE FOR:

• Indirect, incidental, special, consequential, or punitive damages
• Lost profits, revenue, or business opportunities
• Loss of data or information (except as caused by our gross negligence)
• Delays or denials in payment by insurance companies or payers
• Actions or omissions of third parties, including insurance companies

Exceptions

The limitations above do not apply to:

• Our obligations under the HIPAA Business Associate Agreement
• Claims arising from our gross negligence or willful misconduct
• Our indemnification obligations as specified in these Terms
• Liabilities that cannot be limited under applicable law

Indemnification

Client Indemnification

You agree to indemnify, defend, and hold harmless ClainetRCM from any claims, damages, or expenses arising from:

• Your breach of these Terms or applicable laws and regulations
• Inaccurate or incomplete information provided to ClainetRCM
• Services rendered by your organization that are improperly documented or not medically necessary
• Your failure to maintain required licenses, credentials, or certifications
• Fraudulent or illegal billing practices by your organization

ClainetRCM Indemnification

ClainetRCM agrees to indemnify, defend, and hold you harmless from claims arising from:

• Our breach of these Terms or applicable laws and regulations
• Our gross negligence or willful misconduct in performing services
• Unauthorized disclosure of your confidential information by ClainetRCM
• Breach of our obligations under the HIPAA Business Associate Agreement

Intellectual Property

ClainetRCM's Intellectual Property

ClainetRCM retains all ownership rights to our proprietary software, systems, processes, methodologies, and materials. You are granted a limited, non-exclusive, non-transferable license to use our platform solely for the purpose of receiving our services.

Client's Intellectual Property

You retain all ownership rights to your data, patient information, clinical documentation, and business records. ClainetRCM claims no ownership over your intellectual property.

Feedback and Suggestions

If you provide feedback, suggestions, or ideas for improving our services, ClainetRCM may use such feedback without any obligation to compensate you or maintain confidentiality.

Modifications to Terms

ClainetRCM reserves the right to modify these Terms at any time. We will provide notice of material changes by:

• Sending email notification to the address on file for your account
• Posting the updated Terms on our platform with a new effective date
• Displaying a prominent notice in our service platform

Continued use of our services after the effective date of changes constitutes acceptance of the modified Terms. If you do not agree to the changes, you may terminate services as provided in the Termination section.

Force Majeure

Neither party shall be liable for failure to perform obligations due to circumstances beyond their reasonable control, including:

• Natural disasters, fires, floods, earthquakes, or severe weather
• War, terrorism, civil unrest, or government actions
• Epidemics, pandemics, or public health emergencies
• Utility failures, telecommunications outages, or internet disruptions
• Labor disputes, strikes, or workforce shortages

The affected party must provide prompt notice and make reasonable efforts to resume performance as soon as possible.

Dispute Resolution

Good Faith Negotiation

In the event of any dispute arising from these Terms, the parties agree to first attempt resolution through good faith negotiation between senior representatives of each party.

Mediation

If negotiation does not resolve the dispute within 30 days, the parties agree to participate in mediation before a mutually agreed-upon mediator. Each party shall bear its own costs of mediation, with mediator fees split equally.

Arbitration

If mediation is unsuccessful, disputes shall be resolved through binding arbitration in accordance with the Commercial Arbitration Rules of the American Arbitration Association. The arbitration shall take place in Boston, Massachusetts.

Exceptions

Either party may seek injunctive relief in court to prevent irreparable harm or to protect intellectual property rights without first pursuing the dispute resolution procedures outlined above.

Governing Law and Jurisdiction

These Terms shall be governed by and construed in accordance with the laws of the Commonwealth of Massachusetts, without regard to its conflict of law provisions.

Any legal action or proceeding not subject to arbitration shall be brought exclusively in the state or federal courts located in Boston, Massachusetts, and both parties consent to the jurisdiction of such courts.

General Provisions

Entire Agreement

These Terms, together with your service agreement, Business Associate Agreement, and Privacy Policy, constitute the entire agreement between you and ClainetRCM regarding our services and supersede all prior agreements and understandings.

Severability

If any provision of these Terms is found to be unenforceable or invalid, that provision shall be modified to the minimum extent necessary to make it enforceable, or if that is not possible, it shall be severed from these Terms. The remaining provisions shall continue in full force and effect.

Waiver

No waiver of any provision of these Terms shall be deemed a further or continuing waiver of that provision or any other provision. ClainetRCM's failure to assert any right or provision under these Terms shall not constitute a waiver of such right or provision.

Assignment

You may not assign or transfer these Terms or your rights and obligations hereunder without ClainetRCM's prior written consent. ClainetRCM may assign these Terms in connection with a merger, acquisition, or sale of all or substantially all of our assets.

Notice

All notices under these Terms shall be in writing and sent to the addresses specified in your service agreement. Notices may be delivered by email, certified mail, or courier service and shall be deemed received when actually received or three business days after sending, whichever is earlier.

Headings

Section headings in these Terms are for convenience only and shall not affect the interpretation of these Terms.

Questions About These Terms

If you have questions about these Terms of Service or need clarification on any provision, contact us before you sign. We would rather answer a hard question now than have you discover a surprise later.

• Email: info@clainetrcm.com
• Phone: +1 (339) 337-9616
• Location: Boston, MA, United States
• Hours: Mon - Fri, 9:00 AM - 6:00 PM ET
• Online: Contact form