Medical Billing, Compliance, & Revenue Recovery Masterclass

Learn how HIPAA's privacy and security rules protect patient information, define PHI, govern necessary disclosures for treatment or payment, and require safeguards to prevent breaches by covered entities and associates.

Protect PHI by implementing physical, technical, and administrative safeguards that restrict access, secure disposal, encrypt data, and enforce the minimum necessary standard for medical billing workflows.

Explore how the office of inspector general protects medicare and medicaid, and apply seven-element compliance guidelines with policies, training, and internal audits to prevent upcoding and unbundling.

Distinguish between healthcare fraud and abuse by intent; civil penalties for abuse and criminal consequences for fraud, and empower billers to flag inconsistencies.

Understand the Stark Law and anti-kickback statute, their civil and criminal implications, and how improper referrals trigger fraudulent claims and strict liability in designated health services.

Master ICD-10-CM diagnosis coding to establish medical necessity and ensure accurate insurance billing: understand alphanumeric structure, 3-character base, decimal detail, side specificity, and 7th-character extensions.

Master CPT procedure codes and modifiers, including EM codes, and learn how linking CPT to ICD-10 diagnoses ensures proper reimbursement.

Explore HCPCS Level II codes, used for non CPT items like supplies, DME, and drugs, and learn how modifiers, J codes, and accurate units ensure proper Medicare and Medicaid billing.

Learn to link diagnosis codes to the correct procedure codes to prove medical necessity and prevent claim denials. Discover how coverage policies and thorough chart documentation support these links.

Master the CMS-1500 claim form structure, including boxes 1–13 for patient and insurance details, and boxes 14–33 for clinical reasons with ICD-10 codes, CPT/HCPCS service lines, charges, and payment routing.

Explore how the UB-04 form standardizes hospital billing with form locators, a middle revenue-code grid, and detailed admission, discharge, and payer information, including principal diagnosis and RCD-10 codes.

Capture accurate patient demographics and insurance details to ensure clean claims, verify identity, and streamline revenue recovery for the practice.

Verify patient coverage and obtain required authorizations before care to secure payment. Learn how to check deductibles, co-pays, visit limits, and record authorization details to prevent denials.

Translate encounter forms into accurate charge capture by verifying patient details, provider, location, CPT and ICD-10 codes, and auditing entries in the EHR to prevent revenue leakage.

Define clean claims by ensuring accurate patient data, CPT/ICD-10 codes, and provider numbers for automatic processing. Prevent dirty claims by avoiding data-entry errors that trigger rejections.

A healthcare clearinghouse acts as a middleman between medical offices and insurers, routing batch claims, scrubbing errors, and translating data into HIPAA 5010 for faster, denial-free revenue cycle management.

Explore the payer adjudication lifecycle from automated front-end edits and clean claims to clinical logic checks, manual review, and final outcomes—paid, pended, or denied, with explanations of benefits.

Learn to read and reconcile EOBs and ERAs, identify billed, allowed, and paid amounts, apply contractual adjustments, and post patient responsibility using CARCs and RARCs for accurate remittance processing.

Learn how to categorize and resolve standard claim denials by analyzing administrative, medical necessity, and coding issues, and implement root-cause fixes to improve clean claim rates and revenue recovery.

Improve accounts receivable management using an aging report framework that prioritizes 0–30 day claims. Track and pursue denials with structured appeal levels and an evidence-packed submission process.