Claims, Appeals, and Compliance

This unit develops students’ skills in managing the claim lifecycle, responding to denials, and ensuring documentation and coding meet payer and regulatory expectations. Students practice verification, clinical documentation improvement, appeals, audit readiness, and interactions with Medicare/CMS to ethically maximize appropriate reimbursement and prepare for certification and career steps in the final unit.

Learning Objectives

• Analyze remittance advices, claim status reports, and payer responses to identify denial reasons and determine corrective actions across the claim lifecycle
• Apply accurate coding and documentation practices (ICD-10, CPT, E/M) and patient insurance verification procedures to prepare clean, medically necessary claims
• Demonstrate preparation and execution of formal appeals and communications with payers and Medicare contractors, following CMS guidance and step-by-step appeal protocols
• Evaluate audit findings and compliance risks by performing claim scrubbing, detecting unbundling/overbilling issues, and implementing documentation improvement and remediation strategies