Part VI — Getting Paid: Denials, Appeals, and Accounts Receivable

Chapters 29–32

Everything before this part assumed the system works. This part is about what happens when it does not — which, depending on the practice, the payer, and the specialty, is somewhere between five and twenty percent of the time on first submission.

A denial is not a failure of the claim. A denial is a decision, made by a payer applying its own rules to the information you gave it, and it can be right, wrong, or right-but-fixable. Learning to tell those three apart quickly is the highest-paid skill in the business office, and it is almost entirely absent from certification curricula.

Chapter 29 builds the taxonomy. Eligibility, authorization, coding, documentation, timely filing, coverage, duplicate — seven families that between them account for the overwhelming majority of denials, each with a different owner and a different fix. It teaches the distinction between a hard and a soft denial, between preventable and not, and — the one that changes how a business office is run — the discipline of classifying by root cause rather than by symptom. A denial log that says "coding" teaches nobody anything. A denial log that says "E/M with minor procedure, payer edit, requires records" produces a scrubber rule that eliminates the category.

Chapter 30 is appeals. When to appeal and when not to. What an appeal must contain to be considered, and the four kinds of evidence that actually move a reviewer: the note, the payer's own policy, the relevant manual, and the edit file. The anatomy of a letter that wins. Commercial appeal levels and their deadlines, the five levels of Medicare appeal and where each one goes, the peer-to-peer and who should make that call, external review, and a tracking system that keeps an appeal from expiring in somebody's inbox.

Chapter 31 is accounts receivable — the standing pile of money that has been earned and not collected. Aging buckets, days in AR and how to compute it without flattering yourself, the number hiding inside "AR over ninety," how to build a work queue that finds money instead of processing accounts, follow-up technique, write-off thresholds and the arithmetic of deciding to stop, credit balances and unapplied cash, and overpayments — including the sixty-day rule, which converts a retained overpayment into a False Claims Act exposure and which a great many practices do not know exists.

Chapter 32 is the patient. Over the last two decades the patient has become the third-largest payer in American healthcare, and most organizations bill them with tools designed for insurers. Estimates and what makes one honest, good faith estimates and the No Surprises Act, the balance-billing protections that are now federal law, hospital price transparency, statement design, payment plans, financial assistance policies and the fact that most of the people eligible for them never hear about them, collections and the reputational arithmetic, and how to explain a bill to a person who is frightened.

Account 10-4471 is denied in Chapter 29, appealed in Chapter 30, sits in an aging bucket for forty-nine days in Chapter 31, and generates a \$47.58 patient statement in Chapter 32. By the end of this part the account is at a zero balance and the file is complete. What it cost to get there is a question this part deliberately does not answer.

The themes Part VI carries

A clean claim is a fast claim. Every chapter here is downstream of a claim that was not.

Every day a claim sits, it is worth less. Chapter 31 puts numbers on it.

Compliance is not optional. Chapter 31's sixty-day rule is the sharpest example in the book of a compliance obligation that arrives disguised as a bookkeeping question.

Chapters in This Part