Advanced Claims Resolution and Compliance

This unit focuses on advanced revenue-cycle functions: managing payer relationships, preparing and pursuing appeals, ensuring documentation accuracy in EHRs and files, and maintaining regulatory compliance. It builds on foundational coding and billing skills to prepare students to handle Medicare/Medicaid, workers’ compensation, in-network/out-of-network issues, denials, overpayments, and privacy requirements.

Learning Objectives

• Analyze payer contracts, EOBs, NCCI edits, and in-network/out-of-network provisions to determine correct billing pathways and quantify patient financial responsibility
• Apply Medicare (including Part C), workers’ compensation, and commercial payer appeals processes by preparing and submitting compliant appeal packets and documenting outcomes within required timelines
• Demonstrate adherence to HIPAA and confidentiality standards by implementing secure EHR/file systems, verifying prior authorizations, and performing daily accounts receivable follow-up to ensure accuracy and timely reimbursement
• Evaluate claim denials, overpayments, and recurring billing errors using root-cause analysis and recommend corrective actions to improve reimbursement rates and reduce future denials