December 30, 2025 • 19 mins
Kathy Roe, Managing Attorney, Health Law Consultancy, speaks with Christine Burke Worthen, Member, Epstein Becker & Green PC, about two important yet not always well understood areas of the health care ecosystem, the health care claim lifecycle and medical coding. They discuss why it is important for health law professionals to have a basic understanding of these topics, the role that artificial intelligence is playing, and AHLA’s recently released Health Care Claim Life Cycle 101 & Medical Coding 101 courses, of which Christine contributed. From AHLA’s Payers, Plans, and Managed Care Practice Group.
Watch this episode: https://www.youtube.com/watch?v=qigQfdPfEvs
Learn more about AHLA’s Health Care Claim Life Cycle 101 & Medical Coding 101 courses: https://www.americanhealthlaw.org/education-events/101-online-courses/the-health-care-claim-life-cycle-101-medical-codin
Learn more about AHLA’s Payers, Plans, and Managed Care Practice Group: https://www.americanhealthlaw.org/practice-groups/practice-groups/payers-plans-and-managed-care
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_00 (00:04):
This episode of AHLA's Speaking of Health Law is
brought to you by AHLA membersand donors like you.
For more information, visitAmerican Health Law.org.
SPEAKER_02 (00:17):
Hello, everybody, and welcome back to AHLA's
Speaking of Health Law Podcast.
I'm Kathy Rowe.
I am a managing attorney withHealth Law Consultancy in
Chicago.
It's a boutique health law firmthat focuses on regulatory
counseling and contracting.
(00:38):
I'm here today on December 22ndwith Christine Worthen.
I am the chair of the PayersPlans and Managed Care Practice
Group.
And Christine is one of our vicechairs.
She is going to be chatting withme today about her contribution
(01:00):
to an AHLA 101 program.
And so, Christine, why don't westart off by introducing
yourself and telling folks aboutwhat you've done with AHLA?
SPEAKER_01 (01:14):
Great.
Thanks, Kathy.
So, yes, Christine Worthen.
I am a healthcare regulatory andERISA attorney with Epstein
Becker Green.
I am based in their Washington,D.C.
office.
I've been practicing in thehealthcare regulatory ERISA
space for 25 years.
I've been both in-house with alarge health system, and I've
(01:38):
also been private practice.
I became involved with the AHLAprobably close to 15 years ago.
I started by shadowing thehospital and health systems
practice group.
Then I was fortunate to become avice chair of the payment and
delivery reform practice group.
And then I was the chair.
I then went on to be a vicechair in the regulation,
(02:00):
accreditation, and paymentpractice group.
And at present, I'm completingmy last term as vice chair, as
Kathy mentioned, of the PayersPlans and Managed Care Practice
Group.
Over the years, I've beenfortunate enough to cultivate
relationships with a bunch ofincredibly talented
practitioners, and I've beenable to contribute to numerous
(02:22):
live presentations, webinars,articles, podcasts, and books.
I'm glad to be here.
SPEAKER_02 (02:30):
Thanks, Christine.
So why don't you tell me and ouraudience a bit about the 101
programs that AHLA offers and inparticular the 101 claims and
coding series to which youcontribute?
What is it and how'd you getinvolved?
SPEAKER_01 (02:52):
So this was an invitation to give a basic, as
the name implies, 101 basicintro to claims and coding
process.
And my piece is focused on theclaims process.
Two colleagues of mine atEpstein Becker Green, Rob
Wanderman and Will Walters, tookthe laboring or on the coding
(03:14):
piece.
And it's meant to be not just aninformational overview by way of
a slideshow kind of approachwith the relevant information,
but it's also meant to givebite-sized synopses from the
presenters in terms of practicaltips and guidance that you might
(03:41):
find along the way.
I think that it does a nice jobof getting the information
across in bite-sized manageablechunks without going too deep in
the weeds.
But it would allow apractitioner who's not
necessarily familiar with thespace to get some basic
terminology down, some basicthings that would be relevant to
(04:06):
their practice and help to, youknow, maybe pique some more
interest or at least beconversant in the area as they
do their day-to-day jobs.
SPEAKER_02 (04:17):
Christine, one of the questions that I do have and
want to get your answer to iswhy is it important for AHLA
members right now to be learningand understanding the healthcare
claim lifecycle?
SPEAKER_01 (04:38):
I think that in this environment where we're facing
uh reimbursement headwinds,changes in Medicare Advantage,
uh payer policy, I think thatthe notion of submitting
complete and accurate claimsbecomes more and more important
(04:59):
for several reasons.
One is Medicare Advantage payersget paid based on uh coding and
what is documented on theclaims.
And what might not be evident isa lot of times in order to
submit a claim, you don'tnecessarily have to put every
single diagnosis, for example,on a claim.
(05:20):
And that becomes more importantas we think about value-based
care and we think about gapclosure, and we think about all
of the other things as you arelooking at outcomes.
And did we do this?
And are we keeping patientshealthy, for example?
Um, and so understanding how theclaims life cycle, and you know,
(05:43):
not necessarily knowing whereall of these things go on a
claim, but being able tounderstand that a clean claim
becomes much more, or at leastfrom the payer's perspective,
becomes much more than justdoing the basics.
It becomes an exercise in uhimproving relationships because
(06:04):
now you're getting all of thatuh rich data that can be
captured in the claim, gettingthat to the payer, the provider
in turn, when they're in avalue-based agreement, can get
some other payer claims intelthat they might not necessarily
have because a patient of theirssought care at another venue,
and so they might have some gapsthere.
(06:26):
Um, so really um making surethat folks understand that the
claim submission process isn'tjust a box check to get paid, it
really is about creating areally um robust data set to
make sure that you've got acomplete uh patient profile from
a claims perspective, at least.
SPEAKER_02 (06:45):
Okay.
And so this course is part of aseries on claims and coding.
Can you speak to why coding isimportant for health lawyers to
understand alongside of thehealthcare claims lifecycle?
SPEAKER_01 (07:05):
Yeah.
So complete and accurate codingis another um uh that's that's
very important from a not notjust from a payment, but from a
regulatory perspective.
And um changes in coding, forexample, you know, there's been
some recent changes in EMcoding, um, making sure that
(07:29):
you're staying up to date with,or at least being aware if you
don't necessarily need to knowhow to encode an encounter, but
being able to understand andarticulate, okay, so EM coding's
changed, and now we need tounderstand what that entails.
And then on the flip side,payers come out with policies
(07:49):
from time to time.
Sometimes they involve downcoding, that that seems to be
another hot topic these days,and then just understanding how
the coding process from themedical record and documentation
then feeds into howreimbursement occurs and whether
and to what extent you're in apayer audit that's looking at
(08:11):
coding practices and whether youare doing the due diligence on
the provider side to make surethat coding and education is
there.
Um, also HCC coding is has beenand continues to be a big focus.
And so understanding the basicsthat go into that to be able to,
(08:35):
you know, issue spot, but alsoto be conversant and and to help
uh navigate your client throughthrough those choppy waters.
SPEAKER_02 (08:44):
So listening to it, it sounds like somebody doesn't
need to become a medical codingexpert, like folks have talked
in recent years about techlawyers and becoming an IT
coder.
It sounds like a baselineunderstanding is sufficient in
(09:07):
order for one as a health lawyerto support his or her client,
whether it's a payer or aprovider or other marketplace
participant.
SPEAKER_01 (09:19):
Yeah, I I think that's right.
I think with regard to the rolethat uh we we play as attorneys
in in helping the clientsnavigate you know regulatory
strategic um objectives, thereare always going to be those
boots on the ground folks whohave that deep expertise in the
in the coding space.
(09:40):
And certainly, you know, as Iwork with health systems and
we're we're working on issues,um, building relationships with
the with the revenue cycle teamand those types of individuals
really goes a long way becauseuh um their deep expertise in
the coding arena, coupled withyour ability as an attorney to
(10:02):
flag some of the issues that arecropping up, and then that can
translate into you know thesereally great robust discussions
as to whether or not the the umsome of the you know audits that
they're doing internally mightneed to improve.
Um, maybe there's an opportunityto uh think differently about
(10:25):
payer policy intake and makingsure that you're really
understanding what the payersare saying in their policies.
I know I've seen that come upbefore where folks think that
they're doing everything, quote,correctly, but it's just some of
these nuances in the wordingthat provide an opportunity to
say, hey, we may need to updateyou know this billing logic, or
(10:48):
you know, in worst case, do wehave an overpayment?
And also in the reverse,identifying underpayments and
payments to which you'reentitled.
SPEAKER_02 (10:57):
Listening to you, it prompts me to raise a question
uh that's in almost everyconversation, and that is where
does AI fit in in all of this?
SPEAKER_01 (11:14):
So I think that AI, at least in my experience, has
come in in a couple of places.
Um one is ambient listening andand what that means in terms of
pulling that type of informationin for purposes of medical
record documentation andcapturing, you know, aside from
all the patient consent issues,but being able to feel confident
(11:40):
that what is being transcribedis complete and accurate, and
then to the extent that it formsthe medical record to which a
practitioner is signing off onbecomes important.
The other one that I've run intoand seen and advise on is coding
suggestions.
So, based on what is beingpresented in the medical record,
(12:03):
a suggestion for a code may comeup.
And so you always want to bemindful of you know, these codes
are being suggested.
Um, you always want to make surethat the right code's being
suggested, that the physiciansalways, the practitioner,
billing practitioners alwaysmaking sure and doing a double
check on, yep, that code's beensuggested and yes, suggested in
(12:24):
that, and yes, that that is thethe right code.
Um, so I think AI will continue,um especially with the you know
the recent executive order andthe the federal versus state
law, I think it'll continue tobe an area of evolution, but I
also think that there's um roomfor improvement because the the
uh revenue cycle process can beso cumbersome and and and and
(12:49):
involved that um to the extentyou can lighten the load, so to
speak, but also do it in acompliant fashion, I I think is
is a win for everyone.
SPEAKER_02 (12:58):
Let's dig in, talk about the subject of what you
did for your 101 course.
It was on the healthcare claimlife cycle.
Do you want to talk a bit aboutthat and how you tackled that
topic?
SPEAKER_01 (13:15):
Sure.
So the um the the intent or youknow, the the backdrop for the
course is that it's not justabout what you have to do from a
business process perspectiverelated to um healthcare claims,
but also helps to um organizeand present the different laws
(13:39):
that regulate healthcare claimsdepending upon the line of
business.
Um, for example, um, we get intoa bit about CMS, we get into a
bit about the commercial payerclaims processes, some of the
nuances with the different laws,since we've got, you know, No
(14:00):
Surprises Act has come into themix.
And so it's it allows you todistill into different
categories just based upon whichuh lens you're looking through.
Um and it it allows you to kindof have a both a fulsome look at
all of the different um types oflines of businesses as well as
(14:22):
trying to give folks a littlebit of uh distinction among the
different ones so that you canbetter understand how they all
fit together.
Depending upon whether you're inthe managed care space, um
either on the payer or providerside, or you're advising uh
providers and suppliers on theirlines of business, whether it's
(14:45):
fraud, waste, and abuse or basicnuts and bolts and regulatory
requirements.
It's pretty important to justunderstand the basics.
You don't have to have all ofthe knowledge details on
everything that goes intoextraction from the medical
record to the claim submissionprocess and so on, but it does
(15:07):
allow you to understand and youneed to understand the basics
for the claim submission and howeach step in the process is so
important from a regulatoryperspective and making sure that
claims are submitted, thatthey're complete and accurate
claims, and what things may comeinto play when you're in the
(15:27):
process of submitting theclaims, things that you know
payers look at where they thinkthat or they're saying that the
claim is not complete, or ifyou're going through the prior
authorization or the utilizationmanagement process.
And then what happens whenyou're in the appeals process
and in the event you have toproceed to dispute resolution,
(15:50):
it really helps to understandall of the basic components,
including, for example, timelyfiling.
Are you following the appealsprocess, um, making sure you
know certain payers may havedifferent processes for appeals,
which are extremely important tofollow, especially if you're
trying to dispute claims, um,and and understanding look back
(16:12):
periods and the like, um, andmaking sure that you're you're
you understand what a completeclaim looks like and the and
things that may um impactwhether or not a claim was
submitted properly.
SPEAKER_02 (16:27):
I started out my career working for health
insurance, hurricane back all ofthose years ago.
I'm like, I don't think I'veever had any sort of training.
Like, here's where it starts andhere here's where it's it ends.
I just sort of picked it upalong the way.
But as I was watching thecourse, it struck me that it
(16:51):
wouldn't be relevant only forsomebody who, like in my
situation, worked for an HMO ora health insurance company.
It really seemed to have abroader reach.
SPEAKER_01 (17:04):
No matter where you are in the healthcare regulatory
space, I mean, providers uh needto submit claims to get paid.
Um, and so for example,especially in, you know, we've
got Medicare Advantage and we'refacing headwinds as we go into
2026.
You're going to have payers thatare, you know, continue to
(17:28):
implement policies thatproviders would say uh erode the
payment, payers might say orwant to ensure complete and
accurate payment.
And so really understand whatunderstanding what goes into
that claim will allow you tobetter advise your client and to
really get into okay, forexample, a payer policy is
coming out, whether or notpeople are taking uh issue with
(17:52):
two midnight roles and seems tobe a hot trend right now that
the payers are focusing on.
And when you're looking atunderstanding claim submission,
um impacts of medical records,um, especially coverage and
payment issues and all thosenuances, understanding the
(18:13):
basics of the claim submissionprocess, um, I feel is is quite
helpful as you try to navigatethose choppy waters for your
client.
SPEAKER_02 (18:21):
All right.
I think that's uh wrap fortoday.
And I want to thank you,Christine, for coming on and
sharing with the audience alittle bit about the 101 course
that you put together.
And if folks didn't catch thename of that course, it's the
(18:44):
Healthcare Claims Light Cycle,and it's part of a series called
the Claims and Coding Series.
So there's a companion course oncoding.
And otherwise, we just wanted togive you a glimpse of some of
who we are in the payers, plans,and managed care practice group
(19:05):
and the sorts of things thatwe're interested in.
SPEAKER_00 (19:14):
If you enjoyed this episode, be sure to subscribe to
AHLA Speaking of Health Lawwherever you get your podcasts.
For more information about AHLAand the educational resources
available to the health lawcommunity, visit
americanhealthlaw.org and stayupdated on breaking healthcare
industry news from the majormedia outlets with AHLA's Health
Law Daily Podcast, exclusivelyfor AHLA comprehensive members.
(19:37):
To subscribe and add thisprivate podcast feed to your
podcast app, go toamericanhealthlaw.org slash
daily podcast.
This episode of AHLA's Speaking of Health Law is
brought to you by AHLA membersand donors like you.
For more information, visitAmerican Health Law.org.
SPEAKER_02 (00:17):
Hello, everybody, and welcome back to AHLA's
Speaking of Health Law Podcast.
I'm Kathy Rowe.
I am a managing attorney withHealth Law Consultancy in
Chicago.
It's a boutique health law firmthat focuses on regulatory
counseling and contracting.
(00:38):
I'm here today on December 22ndwith Christine Worthen.
I am the chair of the PayersPlans and Managed Care Practice
Group.
And Christine is one of our vicechairs.
She is going to be chatting withme today about her contribution
(01:00):
to an AHLA 101 program.
And so, Christine, why don't westart off by introducing
yourself and telling folks aboutwhat you've done with AHLA?
SPEAKER_01 (01:14):
Great.
Thanks, Kathy.
So, yes, Christine Worthen.
I am a healthcare regulatory andERISA attorney with Epstein
Becker Green.
I am based in their Washington,D.C.
office.
I've been practicing in thehealthcare regulatory ERISA
space for 25 years.
I've been both in-house with alarge health system, and I've
(01:38):
also been private practice.
I became involved with the AHLAprobably close to 15 years ago.
I started by shadowing thehospital and health systems
practice group.
Then I was fortunate to become avice chair of the payment and
delivery reform practice group.
And then I was the chair.
I then went on to be a vicechair in the regulation,
(02:00):
accreditation, and paymentpractice group.
And at present, I'm completingmy last term as vice chair, as
Kathy mentioned, of the PayersPlans and Managed Care Practice
Group.
Over the years, I've beenfortunate enough to cultivate
relationships with a bunch ofincredibly talented
practitioners, and I've beenable to contribute to numerous
(02:22):
live presentations, webinars,articles, podcasts, and books.
I'm glad to be here.
SPEAKER_02 (02:30):
Thanks, Christine.
So why don't you tell me and ouraudience a bit about the 101
programs that AHLA offers and inparticular the 101 claims and
coding series to which youcontribute?
What is it and how'd you getinvolved?
SPEAKER_01 (02:52):
So this was an invitation to give a basic, as
the name implies, 101 basicintro to claims and coding
process.
And my piece is focused on theclaims process.
Two colleagues of mine atEpstein Becker Green, Rob
Wanderman and Will Walters, tookthe laboring or on the coding
(03:14):
piece.
And it's meant to be not just aninformational overview by way of
a slideshow kind of approachwith the relevant information,
but it's also meant to givebite-sized synopses from the
presenters in terms of practicaltips and guidance that you might
(03:41):
find along the way.
I think that it does a nice jobof getting the information
across in bite-sized manageablechunks without going too deep in
the weeds.
But it would allow apractitioner who's not
necessarily familiar with thespace to get some basic
terminology down, some basicthings that would be relevant to
(04:06):
their practice and help to, youknow, maybe pique some more
interest or at least beconversant in the area as they
do their day-to-day jobs.
SPEAKER_02 (04:17):
Christine, one of the questions that I do have and
want to get your answer to iswhy is it important for AHLA
members right now to be learningand understanding the healthcare
claim lifecycle?
SPEAKER_01 (04:38):
I think that in this environment where we're facing
uh reimbursement headwinds,changes in Medicare Advantage,
uh payer policy, I think thatthe notion of submitting
complete and accurate claimsbecomes more and more important
(04:59):
for several reasons.
One is Medicare Advantage payersget paid based on uh coding and
what is documented on theclaims.
And what might not be evident isa lot of times in order to
submit a claim, you don'tnecessarily have to put every
single diagnosis, for example,on a claim.
(05:20):
And that becomes more importantas we think about value-based
care and we think about gapclosure, and we think about all
of the other things as you arelooking at outcomes.
And did we do this?
And are we keeping patientshealthy, for example?
Um, and so understanding how theclaims life cycle, and you know,
(05:43):
not necessarily knowing whereall of these things go on a
claim, but being able tounderstand that a clean claim
becomes much more, or at leastfrom the payer's perspective,
becomes much more than justdoing the basics.
It becomes an exercise in uhimproving relationships because
(06:04):
now you're getting all of thatuh rich data that can be
captured in the claim, gettingthat to the payer, the provider
in turn, when they're in avalue-based agreement, can get
some other payer claims intelthat they might not necessarily
have because a patient of theirssought care at another venue,
and so they might have some gapsthere.
(06:26):
Um, so really um making surethat folks understand that the
claim submission process isn'tjust a box check to get paid, it
really is about creating areally um robust data set to
make sure that you've got acomplete uh patient profile from
a claims perspective, at least.
SPEAKER_02 (06:45):
Okay.
And so this course is part of aseries on claims and coding.
Can you speak to why coding isimportant for health lawyers to
understand alongside of thehealthcare claims lifecycle?
SPEAKER_01 (07:05):
Yeah.
So complete and accurate codingis another um uh that's that's
very important from a not notjust from a payment, but from a
regulatory perspective.
And um changes in coding, forexample, you know, there's been
some recent changes in EMcoding, um, making sure that
(07:29):
you're staying up to date with,or at least being aware if you
don't necessarily need to knowhow to encode an encounter, but
being able to understand andarticulate, okay, so EM coding's
changed, and now we need tounderstand what that entails.
And then on the flip side,payers come out with policies
(07:49):
from time to time.
Sometimes they involve downcoding, that that seems to be
another hot topic these days,and then just understanding how
the coding process from themedical record and documentation
then feeds into howreimbursement occurs and whether
and to what extent you're in apayer audit that's looking at
(08:11):
coding practices and whether youare doing the due diligence on
the provider side to make surethat coding and education is
there.
Um, also HCC coding is has beenand continues to be a big focus.
And so understanding the basicsthat go into that to be able to,
(08:35):
you know, issue spot, but alsoto be conversant and and to help
uh navigate your client throughthrough those choppy waters.
SPEAKER_02 (08:44):
So listening to it, it sounds like somebody doesn't
need to become a medical codingexpert, like folks have talked
in recent years about techlawyers and becoming an IT
coder.
It sounds like a baselineunderstanding is sufficient in
(09:07):
order for one as a health lawyerto support his or her client,
whether it's a payer or aprovider or other marketplace
participant.
SPEAKER_01 (09:19):
Yeah, I I think that's right.
I think with regard to the rolethat uh we we play as attorneys
in in helping the clientsnavigate you know regulatory
strategic um objectives, thereare always going to be those
boots on the ground folks whohave that deep expertise in the
in the coding space.
(09:40):
And certainly, you know, as Iwork with health systems and
we're we're working on issues,um, building relationships with
the with the revenue cycle teamand those types of individuals
really goes a long way becauseuh um their deep expertise in
the coding arena, coupled withyour ability as an attorney to
(10:02):
flag some of the issues that arecropping up, and then that can
translate into you know thesereally great robust discussions
as to whether or not the the umsome of the you know audits that
they're doing internally mightneed to improve.
Um, maybe there's an opportunityto uh think differently about
(10:25):
payer policy intake and makingsure that you're really
understanding what the payersare saying in their policies.
I know I've seen that come upbefore where folks think that
they're doing everything, quote,correctly, but it's just some of
these nuances in the wordingthat provide an opportunity to
say, hey, we may need to updateyou know this billing logic, or
(10:48):
you know, in worst case, do wehave an overpayment?
And also in the reverse,identifying underpayments and
payments to which you'reentitled.
SPEAKER_02 (10:57):
Listening to you, it prompts me to raise a question
uh that's in almost everyconversation, and that is where
does AI fit in in all of this?
SPEAKER_01 (11:14):
So I think that AI, at least in my experience, has
come in in a couple of places.
Um one is ambient listening andand what that means in terms of
pulling that type of informationin for purposes of medical
record documentation andcapturing, you know, aside from
all the patient consent issues,but being able to feel confident
(11:40):
that what is being transcribedis complete and accurate, and
then to the extent that it formsthe medical record to which a
practitioner is signing off onbecomes important.
The other one that I've run intoand seen and advise on is coding
suggestions.
So, based on what is beingpresented in the medical record,
(12:03):
a suggestion for a code may comeup.
And so you always want to bemindful of you know, these codes
are being suggested.
Um, you always want to make surethat the right code's being
suggested, that the physiciansalways, the practitioner,
billing practitioners alwaysmaking sure and doing a double
check on, yep, that code's beensuggested and yes, suggested in
(12:24):
that, and yes, that that is thethe right code.
Um, so I think AI will continue,um especially with the you know
the recent executive order andthe the federal versus state
law, I think it'll continue tobe an area of evolution, but I
also think that there's um roomfor improvement because the the
uh revenue cycle process can beso cumbersome and and and and
(12:49):
involved that um to the extentyou can lighten the load, so to
speak, but also do it in acompliant fashion, I I think is
is a win for everyone.
SPEAKER_02 (12:58):
Let's dig in, talk about the subject of what you
did for your 101 course.
It was on the healthcare claimlife cycle.
Do you want to talk a bit aboutthat and how you tackled that
topic?
SPEAKER_01 (13:15):
Sure.
So the um the the intent or youknow, the the backdrop for the
course is that it's not justabout what you have to do from a
business process perspectiverelated to um healthcare claims,
but also helps to um organizeand present the different laws
(13:39):
that regulate healthcare claimsdepending upon the line of
business.
Um, for example, um, we get intoa bit about CMS, we get into a
bit about the commercial payerclaims processes, some of the
nuances with the different laws,since we've got, you know, No
(14:00):
Surprises Act has come into themix.
And so it's it allows you todistill into different
categories just based upon whichuh lens you're looking through.
Um and it it allows you to kindof have a both a fulsome look at
all of the different um types oflines of businesses as well as
(14:22):
trying to give folks a littlebit of uh distinction among the
different ones so that you canbetter understand how they all
fit together.
Depending upon whether you're inthe managed care space, um
either on the payer or providerside, or you're advising uh
providers and suppliers on theirlines of business, whether it's
(14:45):
fraud, waste, and abuse or basicnuts and bolts and regulatory
requirements.
It's pretty important to justunderstand the basics.
You don't have to have all ofthe knowledge details on
everything that goes intoextraction from the medical
record to the claim submissionprocess and so on, but it does
(15:07):
allow you to understand and youneed to understand the basics
for the claim submission and howeach step in the process is so
important from a regulatoryperspective and making sure that
claims are submitted, thatthey're complete and accurate
claims, and what things may comeinto play when you're in the
(15:27):
process of submitting theclaims, things that you know
payers look at where they thinkthat or they're saying that the
claim is not complete, or ifyou're going through the prior
authorization or the utilizationmanagement process.
And then what happens whenyou're in the appeals process
and in the event you have toproceed to dispute resolution,
(15:50):
it really helps to understandall of the basic components,
including, for example, timelyfiling.
Are you following the appealsprocess, um, making sure you
know certain payers may havedifferent processes for appeals,
which are extremely important tofollow, especially if you're
trying to dispute claims, um,and and understanding look back
(16:12):
periods and the like, um, andmaking sure that you're you're
you understand what a completeclaim looks like and the and
things that may um impactwhether or not a claim was
submitted properly.
SPEAKER_02 (16:27):
I started out my career working for health
insurance, hurricane back all ofthose years ago.
I'm like, I don't think I'veever had any sort of training.
Like, here's where it starts andhere here's where it's it ends.
I just sort of picked it upalong the way.
But as I was watching thecourse, it struck me that it
(16:51):
wouldn't be relevant only forsomebody who, like in my
situation, worked for an HMO ora health insurance company.
It really seemed to have abroader reach.
SPEAKER_01 (17:04):
No matter where you are in the healthcare regulatory
space, I mean, providers uh needto submit claims to get paid.
Um, and so for example,especially in, you know, we've
got Medicare Advantage and we'refacing headwinds as we go into
2026.
You're going to have payers thatare, you know, continue to
(17:28):
implement policies thatproviders would say uh erode the
payment, payers might say orwant to ensure complete and
accurate payment.
And so really understand whatunderstanding what goes into
that claim will allow you tobetter advise your client and to
really get into okay, forexample, a payer policy is
coming out, whether or notpeople are taking uh issue with
(17:52):
two midnight roles and seems tobe a hot trend right now that
the payers are focusing on.
And when you're looking atunderstanding claim submission,
um impacts of medical records,um, especially coverage and
payment issues and all thosenuances, understanding the
(18:13):
basics of the claim submissionprocess, um, I feel is is quite
helpful as you try to navigatethose choppy waters for your
client.
SPEAKER_02 (18:21):
All right.
I think that's uh wrap fortoday.
And I want to thank you,Christine, for coming on and
sharing with the audience alittle bit about the 101 course
that you put together.
And if folks didn't catch thename of that course, it's the
(18:44):
Healthcare Claims Light Cycle,and it's part of a series called
the Claims and Coding Series.
So there's a companion course oncoding.
And otherwise, we just wanted togive you a glimpse of some of
who we are in the payers, plans,and managed care practice group
(19:05):
and the sorts of things thatwe're interested in.
SPEAKER_00 (19:14):
If you enjoyed this episode, be sure to subscribe to
AHLA Speaking of Health Lawwherever you get your podcasts.
For more information about AHLAand the educational resources
available to the health lawcommunity, visit
americanhealthlaw.org and stayupdated on breaking healthcare
industry news from the majormedia outlets with AHLA's Health
Law Daily Podcast, exclusivelyfor AHLA comprehensive members.
(19:37):
To subscribe and add thisprivate podcast feed to your
podcast app, go toamericanhealthlaw.org slash
daily podcast.
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