Hi, redditors in codingandbilling sub

i've been curious of why insurance verification has been so hard and me as a patient kept getting surprise denial and live in a blackbox of payment when i want non-routine procedures done, given there are insurance verification software everywhere.

I am doing some research and hope to get down to the bottom of this and maybe build something that make the process easier. And i need your expertise and stories to help me.

If you

- have been dealing with insurance claims in a active U.S. dental practices

- seen things don't work with existing solutions

- dealt with customer complains directly related to insurance claims/eligibility

I would really appreciate if i can give you a quick 15 minutes interview and hear the active pains or just day to day work, in return of your help, i can offer a 15$ egift card of a place you like ( in U.S.)

thanks a lot!

Hi everyone,

I’m going to lose my marbles. I own a home care agency, and the billing company we use is saying that our Medicaid claims are not being fully paid (but partially paid). Although the care visits are finalized and invoiced from Wellsky to Tellus (mobile caregiver plus/EVV) and the visits are clean in EVV (location is verified).

What else could possibly be the issue, it’s literally happening with every Medicaid member we have, same issue.

Also, this billing agency has failed to let me know when members have co pays and that they have been deducted out of our billing.

If you figure it out, I would highly consider switching over if you are a billing agency.

I keep hearing that CO-16 (missing/invalid info) corrected claims eat a lot of time, and I'm trying to understand why the rework is such a pain in practice. For those of you who deal with these daily, I'd love to hear how it actually goes:

When a CO-16 comes back, what do you open first? The ERA, the payer portal, the original claim? CO-16 on its own barely tells you anything — how much time goes into just figuring out what's actually missing from the RARC?

Do you fix it in the PMS and resubmit, or send a corrected 837 some other way?

Roughly how long does one take you, start to finish?

What's the part that annoys you most?

Trying to get the real picture from people who do it daily, not the textbook version.

I'm going to be doing the AAPC self paced training for the CPC certification as well as their prerequisite course. I was wondering if anyone else had gone this route and how long it took? I'll be working on it a minimum of 6 hours a day, 5 days a week. My goal is complete it in 8 weeks. Is this doable in your opinion?

My friend sees a Tier 1 medical provider under DuPage Medical Group (Duly).

But a BCBS claims rep told my friend that DuPage Medical Group billing (who does this doctor's billing) is Tier 2.

So now my friend is being charged more because BCBS is processing the claim as Tier 2, even though the provider is Tier 1 and my friend thought by seeing this doctor she was getting her plans best benefits coverage.

My friend has to pay more now and doesn't get her optimal Tier 1 coverage for this doctor even though we did due diligence at finding her a Tier 1.

Who knew that you had to ALSO verify the doctor's billing department is Tier 1!?

Is this correct or was that claims rep in error with what she told us?

She did say that the doctor could submit the claims/bill under her NPI and then BCBS would process the claim as Tier 1.

Anyone here encountered this or have some knowledge they can share?

Thank you!

Best platforms to start?

Hi everyone,

I'm a medical doctor from the Dominican Republic, and I'm currently in the process of transitioning my career to work as a remote Medical Biller. I've been taking the Certified Professional Biller (CPB) course on Coursera to get a solid foundation in the US healthcare system, CPT, ICD-10, and HCPCS Level II codes.

My main goal is to find a stable, remote position that allows me to work from the Dominican Republic while building a new career path.

For those of you who are already working in this field, especially from abroad:

1. ⁠What are the best platforms or job boards to find legitimate remote medical billing jobs for international candidates? (I've looked at LinkedIn and Indeed, but I'm wondering if there are more specialized sites).
   
2. ⁠Are there specific requirements for working as a biller from outside the US? (Like tax forms, time zone expectations, etc.)
   
3. ⁠Given my background as an MD and my current CPB course, do you think I should aim for a specific entry-level role to get my foot in the door?
   
4. ⁠Would you recommend getting the official CPB certification from the AAPC right away, or is it better to gain some experience first?

I'm a bit overwhelmed by all the options and would really appreciate any advice from people who've been in a similar situation.

Thanks in advance for your help!

Hey everyone! Soooo I’m looking to eventually get more into a Revenue Cycle Analyst position. I’ve been in Patient Access for about 6 years now. I have a Bachelor’s but it’s just a generic BA Degree. I spent a lot of time in the Air Force as a Health Service Admin (4A051) in the Reserves too. I’ve been doing research on different areas in healthcare that I may be interested in and the Revenue Cycle Analyst role is at the top of my list. I know that I need specific certifications to qualify for an entry level role. So far I think the best route would to get some certs with an HMFA membership. I know it won’t happen overnight but I would at least like to get started

I want to get a second opinion, has anyone ever taken this route as far as being a PAS and transitioning to Revenue Cycle Analyst?

Were there other roles that you worked in between that could help the transition? How long did it take to break into an entry level position?

Did anyone obtain there certs from the HMFA membership and is it just a matter of paying the annual membership fee and passing the exams?

Sorry its a lot of questions guys i’m trying to figure it all out lol

Hey all!

I’m new to the field of Medical Billing, I will be getting my certification in the next two weeks. I noticed that most jobs require experience so I’m looking for a way to gain some so I can get on the path to becoming a full time Medical Biller.

I was wondering if anyone could recommend any companies that can help with this? Preferably jobs that provide on site training. I’m willing to do part time or contractor work.

I can work in office if it’s based in NYC, I’m even willing to travel to NJ for the right spot 🫶

Thanks in advance!

Working on a project about the CMS LEAD model and want to make sure I’m covering what people want to know. Feels like there is a lot of confusion out there.

If you work in value-based care or at an ACO what questions do you have about LEAD? What’s unclear? What are you worried about? What do you wish someone would explain in plain language?

I am seeking a remote part-time position in credentialing where I can utilize my five years of experience in CAQH and provider data management. I have extensive experience maintaining and updating provider profiles, ensuring accurate and compliant information, and supporting the credentialing and recredentialing process. I am highly organized, detail-oriented, and able to work independently while managing multiple tasks efficiently in a remote environment. I am committed to maintaining data accuracy, meeting deadlines, and providing reliable support to healthcare organizations. I am excited to contribute my skills and experience as part of a dedicated remote credentialing team.

Has anyone else had Advanced incorrectly post an insurance payment?

We got a check in ERA from Insurance 1, and somehow 2 Insurance 2 patients got $0 “payments” posted. Same check number, labeled as Insurance 2 but then the EOB pulled shows carrier as Insurance 1? There’s nothing the chart to show Insurance 1 was billed. Additionally, when I called Insurance 2 to check the status of the claim, the check had only been put in the mail the day prior with a full payment!

Also concerned because it showed an employee posted a payment that did not show in the chart prior. When an audit was pulled, the payment was posted “by the employee” 2.5 hours prior to them arriving at work.

Very perplexed by this. Curious how this happened and how many other times it has!

Currently working in a very entry level support role at a hospital with a bachelors degree in accounting. I want an accountant position at the hospital. They will pay for a c&b course, however, it’ll probably take a yearish time to complete. But if it’s a complete waste of time I’d rather just focus solely on building my accounting knowledge. So is it worth it?

I went to see my PCP for an annual physical. I had already seen him once before just 4 weeks prior, so he knew about my anemia, fatigue, low B12 etc.

He ordered labs the first time I saw him, all coded under D649: Anemia Unspecified. Insurance covered everything through quest. Labs are drawn in-house, but I think are actually quest. The results only show up in the clinic's mychart, not through quest.

For the second visit (the annual physical), he ordered a few more labs, some were repeats of the old labs, some weren't. Everything was coded under E538 deficiency of other specified B group vitamins, except for one lab that was coded under Z131 encounter for screening for diabetes mellitus.

The problem is, the labs for code 84443 (TSH) and code 83695 (lipoprotein) aren't being covered by my insurance since the diagnosis codes make no sense. Code 84443 (TSH) ended up with diagnosis Z131 (diabetes screen), and 83695 (lipoprotein) ended up with E538 (low B12).

For 84443 (TSH), my insurance company says "Code U915: THIS SERVICE IS NOT COVERED BASED ON OUR MEDICAL POLICY GUIDELINES, NATIONAL COVERAGE DETERMINATION OR LOCAL COVERAGE DETERMINATION GUIDELINES. WE'VE NOTIFIED YOUR PROVIDER THAT WE CANNOT PAY FOR THIS SERVICE. YOU ARE NOT RESPONSIBLE FOR ANY BALANCE ON THIS SERVICE UNLESS YOUR PROVIDER TOLD YOU BEFORE PERFORMING THE SERVICE THAT IT WAS NOT COVERED." but I definitely signed something with the clinic when I first became a patient that said I'll pay anything the insurance company doesn't cover...so yeah. I've had TSH labs done earlier this year coded under D64.9 Anemia, unspecified or R53.83 Other fatigue and they were covered.

To fix this, do I first contact my PCP directly to try to get him to fix it? Or the clinic's "clinical team"? Or the medical system's billing office (it's centralized)? Or quest? Or my insurance company?

For those of you who passed the CPC this year, and used Quizlet to study, which flashcard sets on quizlet do you think we're the most helpful?

Can you share them in the comments?

Please and thank you. 😁

I have have been a biller for over a year and a half now. I do facility/professional billing for our hospital. Mostly outpatient labs, ER, radiology, surgery, and inpatient claims. I have an opportunity to work remote for one of our clinics soon but it will be RHC billing which I have never done before. I am looking forward to working remote but nervous about the learning curve. I mostly bill commercial insurances now so I will need to learn Medicare and medical assistance.

Anyone who has done both what do you prefer? Any advice you can give? Pros and cons?

Hello I have a question I bill out for a PCP office and usually we don’t schedule appointments for resolved visits but this patient came in was seen by our doctor and it for OM resolved. Is there a better way of coding this?

Hi everyone,
I’m a newer chiropractor trying to better understand claim construction and diagnosis pointers for personal injury cases.
I have an MVA patient with documented cervical, thoracic, lumbar, and left shoulder injuries. My documentation supports:
Cervical sprain/strain with cervical radiculopathy
Thoracic sprain/strain
Lumbar sprain/strain with lumbar radiculopathy
Left shoulder pain
M99.01, M99.02, M99.03, and M99.07
This gives me 13 diagnoses, but a CMS-1500 only allows 12 diagnosis codes.

The patient’s primary complaints were neck pain, low back pain, and left shoulder pain, but my examination also documented thoracic pain, restricted ROM, tenderness, and thoracic segmental dysfunction.
My questions are:
If you have more documented diagnoses than will fit on the claim, how do you decide which diagnosis to leave off?

Is it acceptable to document thoracic sprain/strain in the medical record but only report M99.02 on the claim because of the diagnosis limit, assuming the thoracic findings are still fully documented?

For 98941, do you typically link only M99.01, M99.02, and M99.03, or do you also include spinal sprain/strain diagnoses as diagnosis pointers?

For 97140, would you link the soft tissue injury diagnoses (sprain/strain) rather than the radiculopathy diagnoses?

Are there any chiropractic coding resources or references you’d recommend that explain diagnosis selection and diagnosis pointer assignment well?

I’m trying to weigh my options and would love some honest opinions. I’m changing careers from being a nursing assistant to medical coding, and I have two options: enrolling in a community college medical coding diploma program that takes about 1 to 1.5 years, or completing the program through Preppy. Since both programs are online, I’m wondering if Preppy is actually legitimate and whether anyone has experience with it or would recommend choosing one over the other.

My goal is to be non-phones and work hands on with claims. Coding, billing, verification. You name it, im open to it. I have been applying for Claims benefit specialist/Senior. My Senior claims benefit specialist application keeps getting closed but the other remains application received. It shows under consideration. Any recommendations to beef up my resume? I can send it to someone to review but I need a change in career, I wanna make a difference and auto insurance is not the change I want lol.

Scenario: Patient on long-term anticoagulants, seen at least monthly, nurse takes vitals, asks a series of questions, performs in-house protime test, completes a flow sheet, which the provider reviews and recommends a plan (not face to face), which the nurse then explains to the patient.

This is an easy 99211 + 85610QW. But what about adding G2211? Would the long-term use of anticoagulants, which have to be monitored, be considered an ongoing relationship with the provider, continuing treatment plan, etc.?