Revenue Cycle Management and Medical Billing for Experts

Model volume, acuity, and denial rate for payor contracts as random variables using Poisson, normal, and lognormal distributions. Design base, best, and worst scenarios, and validate with data via backtesting.

Explore how actuarial modeling uses seasonality, case mix index, and stop-loss to stabilize forecasts and protect against catastrophic claims, with real-time control charts monitoring CMI and denial rates.

Explore how organizations model and test the financial impact of high-cost drugs and devices through carve-out stress tests, J codes, ASP versus WAC, rebates, and accruals to safeguard revenue integrity.

Explore a contract what-if simulator lab that tests payer assumptions with rvus, cf, pci, and applies bundling rules and ncci edits to guide renegotiation targets.

Launch and operate a Fhir server for billing by integrating coverage, claim, and Eob resources, applying OAuth 2 and Smart on Fhir, and ensuring accurate data mapping and monitoring.

Transform HL7 v2 into FHIR for modern billing, preserving data integrity and interoperability. Map ADT, ORU, and DFT to FHIR resources with idempotency, validation, and golden record stewardship.

Explore the hybrid landscape of prior authorization with FHIR-based APIs, 278 portals, and RPS, guided by CRD and DTR, ensuring evidence capture and reliable SLAs.

Automate remittance posting with an ERA 835 reconciliation microservice using structured data and posting rules. Ensure auditability with observability, traces, dead-letter queues, and orphan and recoupment detection for review.

Navigate mixed mode orchestration to route api, edi, and rpa transactions by payer capability and claim value, with circuit breakers, health checks, audit trails, and manual work baskets.

Examine how NCPDP telecom powers retail pharmacy claims with BIN and PCN, DUR checks, and real-time reversals, while X12 drives medical billing; learn COB sequencing and crossovers to medical claims.

Understand copay accumulators and maximizers used by PBMs to shift costs, spot them in plan documents and POS scripts, and navigate counseling and compliance risks for deductibles and out-of-pocket costs.

Master rebates and chargebacks in the pharmacy revenue cycle by navigating contract terms, eligibility windows, NDC changes, submission and reconciliation, disputes, and net revenue forecasting with dashboards.

Develop a PBM dispute kit using evidence bundles, claim logs, prior authorization documentation, and clinical notes, plus template letters, escalation rules, and KPI tracking to reduce time to secure payment.

Explore the eligibility and compliance framework for the 340 B program, detailing covered entities, GPO exclusions, patient documentation, duplicate discounts, and virtual versus physical inventory with split billing.

Splitbilling engines automate 340b replenishment and pricing, with accumulator logic to classify units into p-40b or GPO buckets, enforcing Medicaid carve-in and carve-out in mixed inpatient and outpatient settings.

Protect 340b program integrity by carve-in files with ud modifiers, crosswalking ndc and j-code claims, and enforcing pre and post adjudication checks with a ready audit binder.

Ensure contract pharmacy oversight under the three P-40b program with disciplined governance, clear performance metrics, and thorough reconciliation, including SLAs, data rights, and quarterly oversight.

Design a 340 B dashboard that consolidates savings, diversion checks, and duplicate flags to guide decisions. Implement source of truth diagrams, ownership, and real-time alerts to ensure audit readiness.

Learn how PDPM drives SNF reimbursement through five case-mix components—PT, OT, SLP, nursing, and non-therapy ancillaries—and consolidated billing. Focus on assessments and documentation with the triple-check process to avoid denials.

See how PDGM drives home health reimbursement through admission source, timing, clinical groups, comorbidity, Oasis data, LUPA thresholds, and timely Noa submissions.

Master hospice billing by understanding the four levels of care, per diem rates, and the aggregate cap, while managing elections, revocations, and transfers under Medicare and Medicaid with compliant documentation.

Master how IRF-PAI and CMG drive IRF payments. Understand LTCH site neutral rules, discharge status and interrupted stays, and carve outs to optimize revenue while preserving compliance.

Prevent denials before claims leave the system by applying a robust pribyl pre-bill review of eligibility, notices, documentation, and post-acute edits, sampling, and dashboards.