Advanced Claims, Compliance & Appeals

This unit prepares students to resolve complex billing challenges by focusing on appeals, payer relations (including Medicare and workers’ comp), and billing compliance. Students will practice protecting patient privacy, using EHR documentation correctly, applying coding edits and payer contract rules, and implementing systems to reduce denials and manage accounts receivable.

Learning Objectives

• Analyze EOBs, payer contracts, and NCCI edits to identify denials, overpayments, out-of-network exposures, and documentation gaps, and recommend corrective actions for each case
• Demonstrate the complete appeals process for commercial payers, Medicare (including Part C), and workers’ compensation claims by preparing required documentation, meeting timelines, and tracking outcomes
• Apply HIPAA, confidentiality, and EHR documentation standards to protect PHI, respond appropriately to alleged breaches or mishandling, and address overpayment recovery obligations in compliance with regulations
• Evaluate and implement front- and back-office systems—prior authorization verification, daily AR follow-up, organized filing, and professional telephone techniques—to reduce denials, accelerate payment, and improve revenue cycle performance