E/M Coding Alert - 2013 Issue 7
Billing: One Billing Question, 4 Steps to Resolution
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Article Overview
This article discusses a practical billing and denial-resolution workflow for claims involving mid-level providers and payer policy mismatches. It is aimed at coders, billers, and practice staff who need to compare Medicare-related billing practices with secondary payer requirements, document payer rules, and understand the administrative steps that may affect whether a claim can be resubmitted or adjusted. The guidance focuses on verifying policies in writing, reviewing internal billing practices, and preparing documentation for future claims management.
Why This Topic Matters
Denials involving provider identity and payer-specific billing rules can create payment delays, compliance concerns, and unresolved balances. This article helps readers understand the broader administrative issues that can determine whether a claim can be corrected, redirected, or written off.
Article Sections
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Don’t take appeals at face value--research before you write off.
Introduces the denial scenario and the article’s focus on researching payer requirements before deciding how to handle an unpaid claim.
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Step 1: Get the Regs in Writing
Discusses verifying payer rules in writing and comparing Medicare-related billing assumptions with secondary payer policies for mid-level providers.
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Step 2: Check Internal Policies
Covers reviewing practice billing procedures and understanding how internal provider-billing choices may interact with payer-specific requirements.
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Step 3: Face the Music
Explains the possibility that a claim may not be processable after adjustment when payer records and claim details cannot be reconciled.
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Step 4: Prepare for the Future
Focuses on documentation practices and maintaining payer policy references for future billing and denial management.
What You Will Learn
- How to approach a claim denial involving provider billing differences
- Why payer policies should be verified in writing
- How internal billing practices can affect claim handling
- How to document payer requirements for future reference
Who Should Read This
- Medical coders
- Medical billers
- Practice managers
- Revenue cycle staff
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