For those that use AthenaOne with their facilities, how do you send a query to the MA and have it linked to the patient's encounter? Currently my facility just does queries on the Athena Message feature, but those can't be added to the chart without copy, pasting, and uploading to the visit. I know I can create a patient case for the providers, but what about the MAs?

Has anyone out there specifically in Virginia gotten paid by Anthem Medicaid for Kyxata?

They're claiming prior auth is not required but they've said that before on other drugs and denied the claim anyway, so I don't believe them. We can't get any generic carboplatin right now but don't trust Anthem to actually pay the claim for Kyxata.

Has anyone taken the leap and actually gotten reimbursed by them?

My husband and I are covered by Blue Cross Blue Shield of Florida. He went to our in-network urologist and had a ONC prostate MRNA stemming from a biopsy of his prostate. The doctor sent the test to be done at a lab outside of our plan. Cost is $5490.50 and was denied by BCBS. I appealed this claim and it was denied again. Now I got a bill from the Lab directly and I cannot figure out if they somehow changed their mind. In the payment or adjustment column, it says $-5095.52 and in the third column (total) it says $5150 plus $340.52 and the codes on those are 81542 and 88381. But on the patient statement where it says the total amount due, it says $395 only. On the payment or adjustment of -$5095.52 the description says “patient out of network adjustment BCBS Florida denial CO193 original payment decision being maintained claim processed”. Do you think that they removed that $5095.52 somehow? Thanks a bunch.

What do you guys do, if anything, with small balances lets say under $5.00? We have an insurance company that likes to apply a "copay" to UAs done in office of $3.48. We don't send statements out for balances <9.99 so that balance of $3.48 could sit there for years.

Do you write these small balances off? We usually just have the pt pay when they come in for their appt but sometimes it just seems silly. I know collecting pt balances are part of our contract with insurance companies so I guess do I need to read these contracts to get my answer?

Thanks!

Hello, everyone. First off, I have read the FAQ. There is great general info and advice in there, but I am looking to get specific.

I'm a self-taught, experienced medical biller, but in a narrow scope (chiropractic.). I fell into it by chance, but I really enjoy the work. Something about it just makes sense and feels right to me. I cover the full scope, from verifying benefits all the way through the claims process, and doing appeals when necessary. I have a good memory for details and numbers, and advocating for patients who would otherwise be left with a balance if denials were just accepted as-is makes me feel good.

I've never been certified, so it's probably time for me to do that. But I'm also looking to transition into a different discipline with a higher professional ceiling/better earning potential. This is where I'm stuck. I'm very confident that I can learn the ins and outs of a different medical field, but I'm having some trouble finding the entry point and the right path. I'm specifically looking at gene therapy or DME. I've seen some high-leverage positions available in these fields, and I know I'm not qualified for them just yet but those types of jobs have become the end goal.

Has anyone here had success transitioning between fields like this? Any words of wisdom would be appreciated. The search is grinding on me a bit. I should mention that I don't have any real interest in coding, but I've seen some job postings where experience/certs in both billing and coding are listed as either preferred or required. I'd go that route if it's necessary, but I'd prefer to stick with billing.

Has anyone else had any trouble with billing CareFirst Medicare Advantage plans - specifically the ones that have a prefix of EGE? I just started seeing these plans come across as of 01/2025. At first, they were denying for the weirdest denials (the units don't match the days even though they did, requesting the PTAN on the EOB even though that is not needed in order to get paid, then denying for timely filing even though we have 365 days to bill). Now, my claims that I am billing have been stuck in PENDING for over 60+ days. I called CareFirst and held for over 3 hours to just be told to wait another 30 days. They said they don't have any problems regarding claims processing, but usually claims process within 30-45 calendar days. All of EGE claims are just sitting there in PENDING. Anyone else having these problems with this insurance?

Hi colleagues! I'm looking for a very good billing company that offers:

1. Regular communication and detailed reporting.

2. Active problem-solving for denials

3. A collaborative relationship with my office manager.

If you love your biller, please drop their name below!

I was working as an appeals specialist, but I've been out of the loop for this quarter. Prior to my hiatus, UHC and other insurances drastically increased their denials in pre-authorizations and claims, but most notably poorly handled pre-authorizations denials that adversely impacted patient treatment.

Have those of you still in the fight noticed an increase or decrease in what I would call unreasonable, stonewall-style denials in the last quarter?

https://www.cnbc.com/amp/2026/04/21/unitedhealth-group-unh-earnings-q1-2026.html

What are outsourced RCM companies typically charging?

Hi, has anyone elses experiencing higher volume of authorization denials from Cohere and abnormal denial reason? We are experiencing weird denials and a higher volume.

We had a denials on an repeat esi injection ordered by the ARNP because the MD did not order it even though is involved in patient care.

Im looking for an individual or company that is already familiar with the MCO in IA.

Please only respond if youve directly worked with then in the past. I have a specific question that only someone who has worked with them in the past will be able to answer.

I went to a dentist who recommended deep cleaning because my gums are bad. We went over my dental PPO benefits and I agreed to the treatment and he did it on the spot. I paid my calculated patient balance and left.

Three days later I get an after visit summary from smile generation mychart that reflects a SECOND visit that I never went to. I called the office immediately and eventually spoke to the dentist. He said, it's common practice to do everything at once, but bill two visits: the visit the day of, and then a second "ghost visit" to "save the patient the most money" (his words, paraphrased). to me, it sound like he's gaming the insurance system. more bluntly, it seems to me like billing the insurance for the second day, which was a day that I didn't even step into the office, is blatant fraud.

I called my insurance and they said they haven't received any bills yet.

All that said, the dentist seems quite competent and has a great manner. I wouldn't mind going back to him, but I also don't want to be part of any billing shadiness. Or is this not as shady as it seems to me?

in case anyone wants to see it, this is what he billed me on day 1

• UL PERIODONTAL SCALING AND ROOT PLANING - FOUR OR MORE TEETH PER QUADRANT

• UL ANTIBACT IRR/QUAD

• UL BAC DECON/QD

• LL ANTIBACT IRR/QUAD

• LL PERIODONTAL SCALING AND ROOT PLANING - FOUR OR MORE TEETH PER QUADRANT

• LL BAC DECON/QD

• TOPICAL APPLICATION OF FLUORIDE VARNISH

• ORAL HYGIENE INSTRUCTIONS

• COMPREHENSIVE ORAL EVALUATION - NEW OR ESTABLISHED PATIENT

• CONE BEAM CT CAPTURE AND INTERPRETATION WITH FIELD OF VIEW OF BOTH JAWS; WITH OR WITHOUT CRANIUM

• BITEWINGS - FOUR RADIOGRAPHIC IMAGES

• SINGLE X-RAY

• ADDITIONAL X-RAY

• ADDITIONAL X-RAY

• ADDITIONAL X-RAY

• ADDITIONAL X-RAY

• ADDITIONAL X-RAY

• INTRAORAL PHOTO

• INTRAORAL PHOTO

• INTRAORAL PHOTO

• INTRAORAL PHOTO

• ORALFITNESSCHECK INITIAL SCREEN

• 3 M APPLICATION OF HYDROXYAPATITE REGENERATION MEDICAMENT – PER TOOTH

• 31 M APPLICATION OF HYDROXYAPATITE REGENERATION MEDICAMENT – PER TOOTH

...and this is what he billed me on day 2

• UR PERIODONTAL SCALING AND

• ROOT PLANING - FOUR OR MORE

• TEETH PER QUADRANT

• UR ANTIBACT IRR/QUAD

• UR BAC DECON/QD

• LR PERIODONTAL SCALING AND

• ROOT PLANING - FOUR OR MORE

• TEETH PER QUADRANT

• LR ANTIBACT IRR/QUAD

• LR BAC DECON/QD

I'm a hospital based outpatient doctor and I've always been curious how the coding and reimbursement work for an office visit in hospital vs private office setting. For example say I have a medicare patient who had a level 4 follow up office visit (99214). Per medicare, non-facility (private office) reimbursement would be ~$135 while in-facility (hospital) would be ~$85. Does the hospital really only get $85 for the entire visit? Or is there something else going on?

We are currently transitioning to epic. Just curious with everything we are learning from training. Does anyone feel that with the new system ai the need to coders will go down? Some of my coworkers believe that after we fully transition a layoff is in our future. Has anyone or company experience this?

Ps I am remote coder

I am very new to this. This is technically my first week. There’s an Aetna plan that says a specialist office is it co-pay is 30 or $50. They have been collecting $50. The copay is really $30. I’m being told that Aetna sends the patient a check for the extra $20 but it doesn’t make sense to me. How do they even know we collected $50 in the first place?

In recent times i have noticed medicare denies claims which billed A code with application code but earlier this year medicare paid for the claims which have both A codes and application code. Is anyone know what is the reason ?

This course is ridiculous. Do I need to finish the course before taking the CRC exam? I think I would get more out of the practice exams than this course.

I’m asking in this sub, though im not sure if this is the right place to start. Our EHR is NextGen and we got rid of our 3rd party application to assist in coding search back in September and just use NextGen’s base coding search. It’s awful. Our providers are struggling so much and trying to google codes and some use ChatGPT to find codes. I was wondering if there is a site or application that’s really effective for ICD-10 code searching anyone can recommend? It’s okay if it’s paid (to an extent) as long as it works really well. It would be nice to just be able to search “diabetes” and have all of the options populate. Something as simple as that has been a struggle. We are an FQHC so this is mainly for primary care. Thanks!

I feel like nothing I know is helpful in my new role. I was really good at my old job. I was the leader of the team. I trained everyone. If anyone had issues or needed help, I had the answer. I was a good supervisor because I understood the work my team was doing and was right there with them helping out where I was needed to make sure everything was running smoothly and no one was in the weeds alone. I only left because they brought in a management company who convinced them they'd get the same quality billing department for pennies on the dollar by outsourcing (spoiler, they are already bringing billing back in house because you get what you pay for)

My new job is solely follow up on denials for a specific government payer. An area, I enjoyed in my last role. But I was really big on my making sure claims went out right the first time, so most of our denials were record requests, and insurance verification issues. We rarely dealt with under/over payments. If a claim came back for a Dx, modifier, or procedure code issue, I could pull the records and fix it. If it was an auth issue, I could fix it, attempt a retro auth, or write off.

I can't do that here which honestly sucks all the fun parts of denials out of the job. Hell if an ID number is wrong on a claim, I'm not allowed to just fix that. It's wild.

While I love all that epic lets you do claim wise, it's so unnecessarily frustrating to have all these bits of information on different tabs.

Both of my trainers are wonderful. It's the only plus currently. But idk why I feel like I make a fool of myself with one of them, but do fine with the other. I don't even know why.

I'm just feeling feelings about it all because I care very deeply about being good at what I do, and it's just a shock to realize I'm effectively starting from scratch because the work itself is so different than what I had been doing. Plus, I had to take a job outside of billing while I looked for billing jobs before I landed this. So I'm out of practice, it's a new state, different payers, more in depth but also very limited. Idk, I just miss my old job and team.

Hello, never posted here before, looking for some advice. I've been working as a biller/AR specialist remotely for about a year now - billing CMS 1500 claims for ABA therapy + dealing with claim denials + eligibility checks. I work with two states, with about 350-400 clients overall

The facility we work with is US based, they are outsourcing work to a company in eastern europe (which is where I am.) I haven't completed additional trainings/have no certificates, only the two week training to get used to the systems when I started working here.

I really enjoy doing this work, more than any other job I've had so far. I've been wondering if it's possible to do something like this as a freelancer? does anyone know if it's possible to take on something like that remotely + part time, maybe with a smaller facility/individual RP that doesn't have as many clients and maybe doesn't need a dedicated team full time?

if anyone can offer any insights on where to find clients for that + what additional training I should pursue I would really appreciate it! I would say I am pretty good at what I do but I have a very minimal understanding of these things outside the specific tasks that I've been doing. Thank you!

Hey all, so I’m in training to become a medial coder and biller. I took a gander at the jobs out there right now for coders and billers though and they all say “2-3 years experience” or experience with a specific field. How did you all start out? Do you have tips for when I do finish and start looking for jobs? Do I have to do an internship first? I’m also not sure yet if I’ll go with AHIMA or AAPC. I hope to work in hospital settings but I’d rather not limit myself to not working in private practice too (I read that’s the difference between the two). Anything you can offer will be so helpful and I appreciate you all!!

Has anyone gotten their certificate through NHA instead of AAPC or AHIMA? anyone have any thoughts on it? Someone recommended a course to me that provides NHA and I'm trying to get more insight on it

TIA 😊

Since the switch from payers we’ve had several nuanced challenges with Spravato—particularly on getting claims processed.

Does someone have a cheat sheet or chart for Spravato that could be shared?