FTLORC Live Denials Q&A! 03/10/26

FTLORC Live Denials Q&A! 03/10/26

*Please note, the connection on the call dropped at the end, which is why there is a sudden cut-off.

Vanessa Moldovan hosts a live community Q&A on denials and reimbursement, emphasizing end-to-end operational knowledge and root-cause fixes rather than siloed work.
Nicolette shares a Medicare claim-rejection issue traced to offshore staff creating duplicate Medicare payer records with incorrect addresses, prompting new claim-entry guidelines. Participants discuss appeal effectiveness over sheer volume and trends in California denials, including Blue Shield requests for additional information and heightened scrutiny of 99213/99214 tied to fraud concerns and diagnosis ordering.
Perva describes Medicare wellness/preventive denials for newly eligible members that required rebilling with 99214 instead of a G code and asks about Medicare crossover failures tied to patients updating secondary coverage with Medicare.
Guadalupe details out-of-network underpayments driven by third-party pricing vendors like MultiPlan/Data iSight, ERISA-based appeal strategies, obtaining pricing in writing, NCCI/edit disputes, and escalation up to payer leadership.
The group also covers documentation precision for time-based behavioral health codes and an orthopedic prior-authorization scenario where an authorized arthroscopy code was denied after a meniscectomy was coded, raising compliance and documentation questions.

00:00 Live Q&A Kickoff
00:55 Medicare Address Setup Errors
02:12 Root Cause Denial Fixes
04:46 99213 Denial Surge
06:57 Wellness Visit Coding Timing
09:09 Medicare Crossover Issues
10:50 Out of Network Underpayments
13:00 ERISA Appeals Strategy
16:40 Bundling and NCCI Disputes
21:05 Escalating to the CEO
24:53 Community Shoutouts and Teaching
26:28 Out Of Network Gap
28:03 Manual And LLM Help
29:05 Automation And Pricing Games
30:39 Multiplan Data Eyesight
32:32 Specialties And New Markets
33:36 Behavioral Health Denials
34:47 Time Based Documentation
36:42 Ortho Prior Auth Denial
42:15 Coding Billing Compliance
46:16 Wrap Up And Thanks