Payer Problems
This happens when a payer says the claim was “processed correctly” but you disagree.
What is an appeal?
This Epic tool is used to organize and assign denied claims to staff.
What is a workqueue?
This denial means the payer says the service wasn’t medically necessary.
What is a medical necessity denial?
This is what you hear before speaking to a payer rep.
What is hold music?
This beverage fuels most denial workdays.
What is coffee?
This payer process often requires long hold times and multiple transfers.
What is calling a payer?
This is the first thing you usually review when a claim is denied.
What is the EOB or remit?
This type of denial is issued when authorization was not obtained.
What is a no authorization denial?
This information is always requested when calling a payer.
What is the claim number?
This month often feels the longest in revenue cycle.
What is January? (will accept December😄)
This denial reason usually means benefits were active, but limits were exceeded
What is benefit maximum reached?
This Epic issue can cause denials when coverage isn’t accurate on the date of service.
What is registration or eligibility error?
This denial occurs when a claim is submitted after the allowed timeframe.
What is untimely filing?
This happens when a call disconnects right before resolution.
What is frustration? 😄
This is something we all want less of next year.
What are denials?
This type of payer plan often has unique rules and frequent changes.
What is a Marketplace plan?
This happens when charges or modifiers don’t match payer policy.
What is a coding-related denial?
This denial reason means the payer combined services into one payment.
What is bundled?
This should always be documented after a payer call.
What is call reference number?
This improves when teams communicate well.
What is Fewer Conflicts?
This federal protection applies to emergency services even when providers are out-of-network.
What is the No Surprises Act?
This Epic build can prevent denials before a claim is billed.
What is an edit?
This is the process of sending a claim back to payer after correction.
What is a corrected claim?
This phrase usually means the issue is not actually resolved.
What is “processed correctly”?
This is what the team truly deserves after a long year.
What is appreciation (or a break!) 🎉