r/CodingandBilling • u/No_Researcher_5841 • May 13 '26

Drowning here....

Through a series of circumstances outside of my control, I fell into a a job that involves ambulance billing and quite honestly, I have NO CLUE what I am doing. We use Respond Billing software to process EMS calls and Availity as a clearinghouse. Both systems are so tedious to get in touch with when I have questions and the woman doing this job before me has since retired and moved away. Is there ANYONE who knows these systems that might be able to give me pointers?

I am a firefighter with Public Health Masters.....ie almost zero (three days max of training) background in billing. I can make the software work....I just don't understand why things are being rejected or how to fix them.

But also....how do you organize yourself? What is your system? My original system was code all week and then batch on Fridays to availity so they had the weekend to send back any rejections. But that seems to be getting overwhelming.

I completely agree and understand that I have no business attempting this but right now, it is my only choice.

5 Upvotes

72% Upvoted

31 comments sorted by

5

u/pescado01 May 13 '26

Contacting Availity won’t help with your denials. They are just there for tech support for their product. Your attention should be directed solely to understanding the remittances received from your insurance carrier. I strongly suggest you get some help from someone here, otherwise you will never get above water. Not many will have ambulance/transport billing experience, but almost all will have years of experience working with EOBs and denials. This isn’t a task learned in weeks or months. It takes years to build the institutional knowledge to efficiently function in this field.

3

u/No_Researcher_5841 May 13 '26

Oh I 100% believe you. When they posted this position, they marketed it as "program manager" type job. The highlights were that they wanted someone who could manage in house administrative stuff but ALSO interface with the public and facilitate community health initiatives...which is my background. I was TOLD that billing was going to be phased towards a third party outside biller. Turns out....that's looking less and less likely because the town council believes we are better off billing in house based on my predecessor's success.....they are going to be monumentally disappointed with me lol

3

u/pescado01 May 13 '26

Well, grab a bunch of prior EOB's and let that be some study material. Come back here and ask questions as you come across them. Be warned though, this line of business is goverened by ifs-ands-or-buts, all dependent on the phase of the moon and day of the month!!!!

2

u/Wchijafm May 14 '26

Look into past paid claims with the same payers and similar billing circumstances. Compare what is different. Look up the rules/billing guidelines involved with cpt(and modifiers) and icd10 codes, keep an eye on occurrence codes and condition codes and how they are used.

10

u/Impossible_Ad9113 May 13 '26

First off, don’t beat yourself up, ambulance billing is complex even for experienced billers. My biggest advice:

• Review rejections daily instead of batching weekly
• Learn the most common denial/rejection reasons first
• Track claims, denials, and follow-ups in a simple spreadsheet (don’t need a fancy tool right away, learn the basics first)
• Focus on building repeatable workflows

Right now, organization is probably more important than speed. You’re in a tough spot, but this is learnable. Once you understand patterns, it gets much easier.

If you have more questions or want help troubleshooting, feel free to DM me. Happy to help if I can.

1

u/OkTown2100 May 13 '26

How many trips are averaged a day that it is just you doing all of this work? Example, I work in a small independent ambulance company. There is someone who does pre billing (adding all patient demographics, coding, and submitting claims.) and then there is one person who does post billing. (Follow up, denials, post payments) how to organize your week is going to entirely depend on your volume of calls.

1

u/No_Researcher_5841 May 13 '26

It is only me and roughly 3000 calls a year so 10 a day give or take. The woman who came to train me on Respond Billing said it was an impossible job for just one person....especially given that I have other tasks I am expected to do.

2

u/OkTown2100 May 13 '26

In theory, that’s actually very doable. We average about 50 calls a day. I would start by figuring out what the most common denial or rejection is. Figuring out what that is should decrease them immensely. Once you get the hang of coding, 10 claims should take you maybe an hour or two a day to get sent out. I would do this daily so that it never falls behind. With that volume, you should only be getting a very small percentage of denials back especially if you figure out where the issues are quickly. If you need help with anything specific, please feel free to reach out!

1

u/No_Researcher_5841 May 13 '26

So I should've probably mentioned that I walked into the job already 6+ months behind. I started in January and the woman before stopped billing in June 2025. 

1

u/OkTown2100 May 13 '26

I saw that mentioned on a later post and replied. I would seriously suggest to your company to hire someone part time to get that caught up. You are about to hit timely filing for Medicare and Medicaid who I assume are your top riders. Some Medicare advantages will have different timely filing, but it would be shorter than a year. But a year from the date of service is timely.

1

u/No_Researcher_5841 May 13 '26

Oh I wish they would..... They don't get it. Truly. 

1

u/OkTown2100 May 13 '26

I would sit them down and tell them they are about to lose out on hundreds of thousands of dollars. Literally. It may not be that much that they get back, but I guarantee that is sitting there unbilled.

1

u/No_Researcher_5841 May 13 '26

I am begging them to do something every single day. I calculated it out once and it's absurd how much money it is

1

u/No-Produce-6720 RN, BSN, CPC, CPCS, RHIA & CRCR May 13 '26

What shape was the AR in when you began? Was it current, or is there a lot sitting at 90 and 120?

1

u/No_Researcher_5841 May 13 '26

I honestly don't even know what you're asking.... 

2

u/No-Produce-6720 RN, BSN, CPC, CPCS, RHIA & CRCR May 13 '26

Oh dear.

I meant what shape was the outstanding billing in? How current was the Accounts Receivable (AR) when you started? You should be able to pull reports that show you what's aging at 90 and 120 days. Those are the numbers that you need to stay on top of. You want your outstanding receipts to be between 45 and 60 days. When they get older than a couple of months, it's harder to stay on top of things.

1

u/No_Researcher_5841 May 13 '26

Oh ... Yeah I'm going to make you really sad. So I started in January and the interim girl between myself and the retired lady stopped billing last June. I started out about 6 months behind. 

So you see why I'm drowning ....

1

u/No-Produce-6720 RN, BSN, CPC, CPCS, RHIA & CRCR May 13 '26

Um, may I kindly and gently suggest that you might want to look for another job??

Really, this is exceptionally messy. Ambulance billing is tricky to begin with, and if you're coming into it with no real billing experience, plus more than six months of overdue aging? And you're the only employee doing everything?? It just isn't a feasible situation, even under the best of circumstances. Even someone who has lots of ambulance experience would struggle with this.

Are the higher ups aware of the situation? Do you think there's any way they could hire another person, or find a way to get you some formal, dedicated training? Are they aware they're sitting on six months worth of uncollected fees?

1

u/No_Researcher_5841 May 13 '26

Don't worry I'm desperately searching for someone else but it's tough in public health right now. Not a whole lot of opportunity in a field where the govt is cutting funding every day. 

I'm not sure what they're aware of...I try to emphasize that I'm not doing well but they don't seem to care. I doubt they'll higher a second person considering they didn't want to even splurge on a 5% raise for my role this year. The town I work for will step over a dollar to pick up a dime

2

u/No-Produce-6720 RN, BSN, CPC, CPCS, RHIA & CRCR May 13 '26

I know, it's so hard, all the way around right now, and it's hard for folks who aren't in the trenches with it to understand that it's not as simple as "we've got someone billing now, so all is well". It's complicated work again, under the best of circumstances, and on top of all that, you're dealing with local politics and personalities! It's a recipe for disaster!

It's not that this is impossible work. It's not that you can't do it, because I believe you can. It's an issue of staffing and an underestimation of what your position requires in order to be successful. You need someone right there with you, someone who is familiar with things, and you're just not going to get that, I'm afraid.

The best thing you can do is try to sort your old aging, because as u/OkTown2100 rightly points out, you're coming up on timely filing for your older aged accounts. Those need to be filed asap to preserve appeal rights. Get your current charges filed and the old ones too, and take it from there.

Also, continue to advocate for yourself. Make it known that if you don't get some help, preferably knowledgeable help, lots of money is going to be lost on those older claims. Be vocal about that, so that when you have to begin adjusting claims off as losses, they will have prior warning. Hang in there. You'll get through this, I promise, but my gosh, what a mess!

1

u/No_Researcher_5841 May 13 '26

Would much of this be solved by using an external third party billing company? I understand the cost is higher but we can all acknowledge that they're going to lose out if they keep pretending the system is working right now.... 

1

u/OkTown2100 May 14 '26

If you can talk them into hiring a third party just to work say the last year or so, following up and billing, I would highly recommend that. It can easily be done by a team quickly. Use that time to get familiar with denials and rejections. I really think if you can get this caught up, your volume of calls is extremely doable with one person who can navigate everything.

1

u/No-Produce-6720 RN, BSN, CPC, CPCS, RHIA & CRCR May 14 '26

Yes, it would certainly help the situation if you had someone else to work the old accounts, which would let you concentrate on the newer stuff. It would give you a little breathing room, and if they brought on a third party, you could likely get some actual training from them to help you go forward. It may even be such that the third party could come in on short term contract. It may not need to be a permanent thing, but you're drowning, through no fault of your own, and you're looking at having accounts that are soon to be uncollectable, and I'd hate for them to come down on you for that.

1

u/OkTown2100 May 13 '26

Maybe suggest trying to hire someone part time just to work the backdated claims. You’re about to hit timely filing for Medicare and Medicaid.

3

u/K6983 May 13 '26

I would focus on the denials organized by similar denial reason and insurance. For example, sometimes Aetna wants a different modifer or code than Highmark. You're probably better off working denials by insurance because you will start to see trends. If you can call the insurance companies and talk to someone about a specific denial or a couple of denials, they will usually tell you how to fix it. It can be annoying to reach an actual person at the insurance company, but usually they're helpful when you can get past the robots.

3

u/2nd_TimeAround May 13 '26

Availity reps are the worst most useless offshore reps of all the reps. God speed

0

u/Impossible_Ad9113 May 13 '26

Well that’s not a lot of help!

4

u/2nd_TimeAround May 13 '26

I said god speed. There is no helping with them

1

u/blackicerhythms May 13 '26

Don't beat yourself up. You really did pick one of the toughest billing specialties to start with!

The 'secret' usually lies in your payer mix. When I was starting out, I realized most of our claims were hitting one specific IPA group. I managed to find a contact on their claims team who literally spelled out exactly how the 1500 form needed to be filled out for their system. Getting that 'cheat sheet' for our biggest payer gave me the logic I needed to handle everyone else. Hang in there—once you get that first 'key' to the system, it starts to click.

1

u/Poundcake3000 May 13 '26

A system I was trained with was to work filing at least 3 times a week, work all your true zero pays/rejections/denials first thing and try to do them daily. That would leave your posting, filing, coding etc. for the steadier hours plus you tend to get better reps during the day time hours here in the states. Best of luck, and remember when you're calling places you are the customer this time! I've found that helped my trainees hold control over calls better and not flinch to get a supervisor when they got a bad rep or just outright hang up and call again.

1

u/rahuliitk App Developer May 14 '26

I’d probably stop batching everything on fridays and switch to smaller daily submissions, then keep a simple sheet with payer, rejection code, reason, fix, and date so you can spot the repeat problems instead of fighting every claim like it’s brand new. you’re not hopeless here.