Advanced Claims Resolution and Compliance

This unit builds on foundational billing and coding skills to teach advanced claims management, payer appeals, and regulatory compliance. Students will practice resolving denials, navigating Medicare/Part C and workers’ compensation processes, protecting patient privacy, and implementing office systems that improve revenue cycle performance.

Learning Objectives

• Analyze explanations of benefits (EOBs), payer contracts, and NCCI edits to identify coding, coverage, and payment errors and prescribe corrective actions
• Apply formal appeal and payment recovery procedures for commercial payers, Medicare (including Part C), and workers’ compensation by preparing required documentation and meeting payer timelines
• Demonstrate compliance with HIPAA and patient confidentiality standards when managing EHRs, phone communications, and claims information, including appropriate disclosure, authorization, and breach-avoidance practices
• Evaluate and implement office systems—prior authorization verification, daily accounts receivable follow-up, file organization, and overpayment handling—to reduce denials and accelerate accurate reimbursement