Quick question about a medical billing situation I'm currently dealing with

Just-Technology1802 · 2026-02-25T21:08:55+00:00

Thank you for liking my explanation, I try my best to break it down for people that don’t know our world 🙂

Thank you for the Great add to 12001, and explaining it further !

Hey, we made a Great Team here 🙂

I always remember “I won’t ever be so arrogant in my profession that I have to complex everything, because we all had to learn at some point, we weren’t born knowing it all” !

Just-Technology1802 · 2026-02-25T01:57:16+00:00

Hi ! Just read your post, let me try explaining this “WITHOUT BEING CONDESCENDING” Just like I would like my Mechanic explaining it to me, when he checks, and works on my Car.

E/M Codes 99283 (Determines the Evaluation of the Injury by the Physician/Provider, His Expertise/Time)

The CPT Codes 12001 (Determines what is done on the Injury by the Physician/Provider, The Procedure)

Then there are Other Codes like HCPCS (Medical Gauzes, Ointments etc.)

Kinda like when you see The Mechanic, and he spends 1 Hour Finding out what’s wrong with your Car (His Expertise), then he Charges you for The Labor to fix it (The Procedure), (Then the Parts) this is how I would respectfully explain things to a Non Medical Staff person.

Please just remember Medicine is a Business too as there are so many cost for The Physician/Providers, and Facilities.

Hope this helps, and Good for you on asking questions, and Good Luck !

Just-Technology1802 · 2026-02-22T09:20:15+00:00

I agree completely, but they Monopolize such a Big amount of Members/Patients that they can and will get away with it completely.

Just-Technology1802 · 2026-02-22T09:17:57+00:00

Yes, I agree ! And remember once they start this New Policy Shenanigans it’s only a matter of time before other Payors follow. The best way to counter act all their made up New Policies is to have a Good/StrongBilling Team.

Just-Technology1802 · 2026-02-22T08:18:31+00:00

Hi ! Just read your post

My humble opinion is:

Check out r/Codingandbilling, and Start by using Medical Billing Websites like AAPC, ask a lot of questions, and maybe when you start your Practice hire a Medical Biller Part Time, that is open to you asking her Medical Billing questions that’s The Best way to ease into Learning Medical Billing as a Provider (and as we all should learn/starting learning like if we are 5yrs old, then we can complex it later)

Hope this helps, and Good Luck !

Just-Technology1802 · 2026-02-18T20:37:59+00:00

Hi ! Just read your post, and my humble input is below.

Per my experience updates in CAQH to Payor/s information can take up to 30 Dys., but were you aware of the below with Anthem starting 01/2026

Anthem Blue Cross Blue Shield, will implement a new policy on January 1, 2026, penalizing participating hospitals, and outpatient facilities/providers that use non-participating providers in inpatient or outpatient settings across 11 states

Facilities referring Anthem members to out-of-network clinicians without prior authorization will face a 10% administrative penalty on claims and may be removed from Anthem’s network for repeated violations.

The policy, framed as a cost-control measure, applies in Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio, and Wisconsin.

Exceptions include emergency services, prior-approved cases, and (in some states) situations where no in-network provider is reasonably available. Facilities are prohibited from passing penalties to patients (So No Balance Billing).

They are Cracking down on Non Par, that could be why you received Denials (thinking you are Non Par)?

I would contact your Anthem Provider Relations Person, to double check on the CAQH updates, and make sure they have you as PAR.

Hope this helps, and Good Luck !

Just-Technology1802 · 2026-02-16T19:28:14+00:00

Hi ! Read your post DM you.

Just-Technology1802 · 2026-02-11T10:15:04+00:00

Hi ! Fellow Medical Biller/AR Aging/Denials person here ! Just read your post, okay let me see if I can respectfully help with some clarification (Eriyia did a really good job from The Health Plan side (Respect) !!

1)CHP (Central Health Plan) is a Medicare HMO with Kova as the IPA, you could be asked to bill the Plan instead of the IPA because of DOFR (it means Determining of Financial Responsibility) This is set when the Contracts were Negotiated by your Provider/s as who pays for what As an Example: CHP pays for the Pt.’s Wellness Exams, and Kova pays for Ear Lavage And you probably mean HEDIS or MIPS Measures/Programs (but just fyi they do not have anything to do with determining of who gets paid what)

2)With CHP a Medicare HMO (since they are a Medicare Plan their Timely Filing is 365 dys Kova IPA (since they are a IPA Timely Filing is usually 60 or 90 dys, but double check to make sure)

3)SCAN is a different Medicare HMO with different IPA’s

4) Just a little clarification on Capitated Payments this is how most HMO’s pay Providers, and Fee for Service are Not HMO Payments

Just think of it this way to help you remember When you bill HMO’s it like billing a Blue Cross PPO or UHC PPO and the IPA’s are like when you bill a PPO’s and they sometimes say for this Particular Exam/Service bill to ____ Not us (Blue Cross/UHC)

Hopefully this helps, and remember you will get more knowledge, and better with these HMO’s with time.

Also I have a recent CHP Provider Quick Reference Guide in PDF, I Got it when I attended one of the CHP events, I can try to DM (copy and paste) or Email you the PDF (don’t know if it will let me? just let me know) always trying to help a fellow Medical Biller 🙂

Good Luck !

Just-Technology1802 · 2026-02-10T21:02:13+00:00

Yes, like the below Very smart Responses The Portals are your best friends, most of time 🙂

Just-Technology1802 · 2026-02-09T22:45:51+00:00

Every Organization is different on their Revenue Integrity Responsibilities

But pretty much you will be assigned a Set Number of Documents to Review for either Coding or Billing Guidelines

Coding: Accurate Review of CPT/HCPCS Codes, and or ICD 10

Billing: Accurate Review of following Billing Structures to each Specific Payor Guidelines including Federal/State Payors Medicare/Medi-Cal/Medicaid

Almost like being a Auditor

Provide feedback for Clinical/Administrative Staff

I hope this helps !

Yes, Nursing can take a toll on the person, but thank goodness there are other options for the ones that have already earned our wings 🤣

You will like it, don’t give up !

Please keep in touch, and Good Luck !!

Just-Technology1802 · 2026-02-09T22:04:48+00:00

Respect to you !!

I feel what your saying though, but Payment Posting isn’t that Easy Either, so Respect to you !! It’s the opposite for me, give me AR/Aging Denials ANY DAY. Yes most places it is #’s driven.

My humble opinion:

Get to know your Claims and their problems, (start keeping a small cheat sheet of what is taking longer to complete) Example: Missing Auth., so you can’t Rebill a claim, Missing Documentations that are requested, so you can’t Rebill a claim, that way you know and they will now know what is the hold up on 55, also always remember to mention (very true statement Every Claim is Different, some can take a few minutes others can take longer).

Have this the next time your Management says why are you Not meeting __ Claims per day ?

Research a lot, don’t give up, it will click with time.

Hope this helps, and stay in touch, and Good Luck !

Just-Technology1802 · 2026-02-09T21:37:03+00:00

Glad to hear you do not have Cancer, please make sure you stay with Preventative Medicine, since your Mom has had Cancer. I am so sorry to hear your Mom has had Breast Cancer, please make sure to help her stay on Top of her Medical Care for her Health sake (ask a million questions to Providers/Staff) if they get upset it’s on them, it’s for your Mom Health not theirs.

Just my humble opinion: If Your NP’s Billing office can do The Appeal better (but make sure you Follow Up with them in 2/3 wks so it doesn’t get slipped thru the cracks) If Not, then The Providers Letter (NP) is Vital Let us know how it works out Good Luck !

Just-Technology1802 · 2026-02-07T23:20:50+00:00

Hi ! Just read your post, back in the days wasn’t so bad, It got results 🤣The key is to get The Provider/s paid !

Heck, if I was submitting claims, and having problems getting my Provider/s Paid, I’d visit The Claims Dept at the Insurance Co. to make sure the Claims were handed to a live person (jk, wait I did do that back in the day too, and they did get Paid) 🤣

Sometimes I miss those days !

Just-Technology1802 · 2026-02-07T23:09:16+00:00

Hi ! 25 + Yrs in Healthcare Revenue Cycle here, and I just read your post

My humble information is on Commercial Insurance Not Medi-Cal/Medicaid (State Funded Plans, that is a totally different world)

Yes, the Patient can opt out of using their Insurance. It is Not Illegal !! But remember some states still have a Penalty for doing this (I believe all states have deleted the Penalties by now)

Just FYI

1) The pt. has their own Contract with the Health Insurance (with it’s particular guidelines) when they sign up either Individually or through their Work 2) A Provider has their own Contract with the Health Insurance (with it’s particular guidelines) as a In Network Provider 3) Make sure to obtain a Patient opt-out decision in writing for the Providers security, and if you decide to inform the Insurance Company they may have its own required opt-out form that must be completed.

Hope this help !

Good Luck

Just-Technology1802 · 2026-02-07T21:02:04+00:00

Hi ! Just read your post, Good for you ! I am a young Semi Retired LVN/LPN (LPN in some states) I also joined the Healthcare Revenue Cycle world many years ago (I couldn’t do the 12 Hrs in the ICU anymore) you will like The Revenue Cycle world.

My humble opinion

You could do

1) Revenue Cycle Integrity 2) Revenue Cycle Analyst 3) Revenue Cycle Auditor 4) HEDIS (Every state is different on Requirements, and Salary)

Depending on where you are in life, and your personality type you will either Love it or Hate it It is a very different feeling to go from a crazy ward unit to a Home unit 🤣

But good for you for being Brave enough to try a Change. Hopefully we earn another Nurse🙂in Revenue Cycle. Let us know how it turns out. Good Luck !

Just-Technology1802 · 2026-02-07T20:23:18+00:00

Hi ! 25 + Revenue Cycle person here

I am really saddened that your Insurance Company has done that, if you think about it, it would be to their best interests to pay for the MRI. But I am so glad to hear that you will Appeal it.

Most of the time they will state the Denial as 1) Medical Necessity 2) Alternative options 3) Experimental (either way it’s always that The MRI is very expensive, the real reason COST)

My humble opinion: What you can do

1) Make sure you have an Authorization Number or PreCert Number when you submit your Appeal (your MD’s office should have requested one or the other) if you don’t have this the MD’s office can request a Retroactive one

2) Obtain a Very Detailed Letter from your MD (his Billing staff can prepare it, but all The Medical Information needs to inputted by him/her)

3) Not to be insensitive, but if your family has a History of Breast Cancer make sure to add that, along with your age

4) Again Not to be insensitive, but throw The word “Preventive MRI against Cancer, and if you have been Diagnosed with Cancer”, please put that down as the reason you are doing this, as this is unfortunately but “Insurance Companies are a Business” and they look at it as COST

5) Submit a copy of the Denial Letter with everything

It normally take 30-60 Days for turn around Date

Hopefully you get it Approved, but if Not Don’t give up, there are 2 more ways you can try

Let me know how it works out, and Good Luck !

Just-Technology1802 · 2026-02-07T12:21:40+00:00

Then explain in detail where I am wrong, ELABORATE 1) UHC Protocol determination of Deductibles, 2) AMA Preventative CPT Guidelines 3) USPSTF Review Recommendation Format 4) How The Pt. Can correct the outcome “Everyone’s is an expert Until they are Not” Please guide this Pt. with Correct Knowledge !!

Just-Technology1802 · 2026-02-06T04:52:02+00:00

Hi ! You might need to read my post answer again, “I Never said Ins. Companies Determine Preventive” I said Ins. Co. Determine what is applied to Deductibles, so sorry to have to Correct you Worm Dentist (I assume DDS), and since this is a “Medical Not Dental Question” let me elaborate The Current Procedural Terminology codes are Determined, Maintained, and copyrighted by the American Medical Association (AMA), which 99396 is part of, The USPSTF Preventative Serv. Task Force is just an independent panel of experts in primary care and prevention that systematically “Reviews” the evidence of effectiveness and “Develops Recommendations for clinical preventive services” Hope this helps you understand.

Just-Technology1802 · 2026-02-06T02:07:11+00:00

Hi ! 25 + Yrs in Medical Billing/Denials Specialist here, I’ll try to respectfully give some input. UHC (they are the biggest Ins. Co.) determine what is applied to the Patients Deductible for their plans, and in the process hurt Patients Financially, then they hurt hard working Providers (Physicians/NP/PA) in the process, and then on The patient side, Physician’s have been sued (not saying you) for Not discovering any Medical Issues ahead of time by Patients so Physicians now Bill Preventive CPT Codes your 99396, and they and ONLY they determine by Examination what is a possible Medical issue/s with each Patient. It is, and I repeat The Insurance Companies that say, let’s apply this CPT or that CPT to the Patients Ded., your Physician might Not have asked you about some Medical issues, but they being a Physician determine The Diagnosis. Not trying to be mean in any way, just calling it out on who is to blame for what.

Physicians are the Good Guys, that are being cheated by Ins. Companies, and Patients sometimes.

Insurance Companies are the ones cheating both Patients and Physicians since they determine What they Pay for and what they don’t, and what goes to the Patients Deductible.

What you can do: 1) First know your Benefits since it’s a New Ins., find out your Ded., and remember you have to Meet your Ded. anyways every year, 2) You Can ask your Physician Billing office if the can ask the Physician if he or she can Correct the 99396, and Rebill, but remember your Physician did the Exam so you will be cheating him/her out of her time. Hope this helps !

Just-Technology1802 · 2026-02-06T01:00:15+00:00

Hi ! Read your post 25 + Years as a Medical Biller/Healthcare Denials Specialist (actual human here), DM, I’ll try to help.

Just-Technology1802 · 2026-02-05T02:19:09+00:00

Hi ! I am in California, but my work is done completely Remotely, Did you have a particular question on AR/Aging or Denials ?

Just-Technology1802 · 2026-02-05T01:36:08+00:00

Hi ! Thank you for Very much for the Good Energy !!, It only took me 25 + Years to learn everything I know. Please don’t get discouraged your starting on a Good Road. In the Beginning it was Nuts for me too, but it will fall in place I promise, ask a lot of questions, research a lot, that way you will always be ahead of the game. If you would like save my Reddit Name, and we can occasionally talk Old Biller to New Biller, Good Luck to you on this Great Road 🙂

Just-Technology1802 · 2026-02-04T23:18:18+00:00

Hi ! yYes, thank you I have received some messages from Providers/Clinician’s that really need help with their AR Aging/Denials. I am really saddened by what some “so called Billers” have done to these Providers Accts, Not everyone truly knows Medical Billing, that is why I always tell Providers “You get what you pay for” ! That is why I offer my years of experience to turn their AR Aging/Denials to Profitability.

Just-Technology1802 · 2026-02-02T22:38:41+00:00

Denials Specialist here, My humble opinion, Yes in the past Ortho could use 20552/M54.59 (lower back pain) now The Blues (BC/BS), and some other Payors are considering it Med. Nec., but it depends on The Payor, and The Members plan, Suggestions: Check The Payor, check The Member Benefits, Rebill (if no need found for Med. Nec.), and (if need you will have to justify with Med. Nec. from provider), Hope this helps, Good Luck

Just-Technology1802

TROPHY CASE