Key Takeaways A behavioral health carve-out moves mental health and substance use disorder benefits from the medical plan to a managed behavioral health organization (MBHO), whose name may not appear on the front of the patient’s insurance card. Claims sent to the medical plan for carved-out services typically deny with CARC 109, which signals the […]
Denial Management FAQ: Process Questions Billing Teams Ask Most
Key Takeaways A rejection stops a claim before payer review; a denial means the payer reviewed it and declined to pay. Hard denials are not recoverable; soft denials can be corrected, resubmitted, or appealed — and the distinction should drive triage decisions. Medicare Part A and B redeterminations must be filed within 120 days of […]
Common Denials in Medical Billing: What They Are, Why They Happen, and How to Prevent Them
Key Takeaways Medical claim denials cluster into a small number of categories — most practices are dealing with the same types, even if the specific codes and circumstances differ Coding-related denials are the most prevalent and most preventable; they trace to claim elements that don’t align with each other or with payer rules Medical necessity […]
What Is a Clean Claim Rate? Benchmarks, Calculations, and What the Number Won’t Tell You
Key Takeaways A clean claim rate measures the percentage of claims accepted by the payer on first submission, without rejection or request for additional information Industry benchmarks, including those referenced by HFMA, put the target for high-performing operations at 98% — most practices land between 85% and 95%, and that gap has a direct dollar […]
How to Use a Medical Claim Scrubber: A Step-by-Step Walkthrough
Key Takeaways A medical claim scrubber reviews CPT codes, modifiers, diagnosis codes, and claim structure before submission to flag errors that lead to denials Different specialties produce different types of claim errors — the same pre-submission review process surfaces different issues depending on the claim context AI-powered claim scrubbers identify relationships between coding elements that […]
What Is a Claim Scrubber and Why It Matters More Than Ever
Key Takeaways A claim scrubber reviews coding and claim data before submission to identify errors that lead to denials AI-powered claim scrubber software can detect more complex issues than traditional rules-based tools Effective claim scrubbing improves clean-claim rates and reduces rework across the revenue cycle Early validation supports faster reimbursement and more predictable cash flow […]
PGM Billing Launches AI-Powered Medical Claim Scrubber Through RevAIant Partnership
Key Takeaways PGM Billing has partnered with RevAIant to introduce AI-driven claim scrubbing capabilities The solution helps identify coding errors and denial risks before claims are submitted Earlier validation supports stronger clean-claim rates and fewer downstream corrections The AI-powered medical claim scrubber provides immediate feedback without requiring PHI Billing teams gain greater confidence in claim […]
June Bulletin – UnitedHealthcare Updates
UnitedHealthcare Updates UnitedHealthcare released plan updates for June 2022. All plan updates can be found here: UnitedHealthcare Community Genetic testing for hereditary cancer Cardiovascular disease risk tests More than a dozen medication updates UnitedHealthcare Commercial Macular degeneration treatment procedures Ambulance services Liposuction for lipedema UnitedHealthcare Medicare Advantage Cardiac procedures, including pacemakers and defibrillators Urinary and […]
March Bulletin – CMS Announces New Place of Service Code
CMS Announces New Place of Service Code Effective January 1, 2022, a new place of service (POS) code became effective for use. The new POS Code, 10, indicates Telehealth services provided in the patient’s home. Prior to the creation of POS 10, the correct place of service code for all Telehealth visits was 2. Now, […]
February Bulletin – The “No Surprise Act” Causes Confusion
Since the No Surprise Act (NSA) became effective on January 1, 2022, medical offices are experiencing trouble understanding and implanting the new requirements to remain compliant with the NSA guidelines. On January 20, 2022, the Medical Group Management Association (MGMA) called on the Centers for Medicare and Medicaid Services (CMS) and the US Department of […]