The Claim Game

EPISODE SUMMARYIs your private practice’s front office running like a well-oiled machine, or a "clogged emotional drain"? This week on The Claim Game, Jeremy Zug sits down with Brent Metcalf, LCSW, founder of Tri-Star Counseling, to discuss the wild ride of scaling a multi-niche group practice in the Appalachian region.Brent shares the "serendipitous" story of how he was essentially "voluntold" into private practice by his financial advisor and how he grew that accidental start into a thriving team of 11 clinicians. We dive deep into the "hodgepodge" of patient registration—the common headaches of missing insurance cards, tech-averse clients, and the "ickiness" therapists often feel when charging for their time. Whether you’re curious about the strategy behind buying a commercial building or wondering if AI note-taking is the "magic" your documentation needs, Brent’s "Dr. Brent" wisdom offers a masterclass in balancing clinical heart with a "business hat" mindset.KEYWORDSPrivate Practice, Revenue Cycle Management, Mental Health Billing, Appalachia, Group Practice Growth, Patient Registration, Medical Billing, Healthcare Business, Credentialing, Therapy Notes, Jane App, AI NotesTAKEAWAYSThe "Voluntold" Entrepreneur: Brent’s journey proves that sometimes the best business moves happen when you stop overthinking and start saying "yes" to the opportunities that fall into your lap.Registration is the Foundation: A "C-grade" registration process leads to "BAM—denied" claims. Collecting front-and-back insurance card images before the first session is non-negotiable for clean eligibility checks.Mindset Over Money: Charging co-pays and no-show fees isn’t "mean"—it’s essential. If you want to provide high-quality care to underserved regions, you have to keep your own lights on first.Scaling with Culture: Tri-Star uses a "finder's fee" for employees to recruit peers they actually want to work with, ensuring the "open-door policy" stays authentic as the team grows.The Power of Commercial Real Estate: Instead of renting forever, Brent invested in a 20-office building, turning empty space into a "one-stop wellness shop" with massage therapy and psychiatric NPs.AI as a Clinical Ally: Transitioning from "anti-AI" to an advocate, Brent uses AI scribing to stay present with the human on the couch rather than buried in a notebook.CHAPTERS00:00 Introduction: Meet Brent Metcalf and Tri-Star Counseling07:33 Why Patient Registration Keeps Slowing You Down11:37 Improving Intake Through Training and Process17:48 Culture, Compliance, and Client Experience22:38 Scaling the Practice: Growth, Real Estate, and Expansion30:50 Building Community Presence and Referral Networks32:27 Beyond the Practice: Teaching, Supervision, and Consulting33:51 Navigating Insurance, Access, and Practice Economics38:11 Advice for Starting and Scaling a Practice41:56 Leveraging AI for Notes and Treatment Planning44:32 Conclusion: Final Insights for Practice SuccessRESOURCESToday Sponsors: Jane | One Month Grace Period Promo Code: PRACTICESOLUTIONS1MOLearn More About Tri-Star Counseling: tri-starcounseling.comUpheal: https://upheal.io/join?via=YKWVPJ74Heard: https://affiliate.joinheard.com/ucv1vp09xwraLearn More About The Claim Game: Visit practicesol.com/podcastThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance. Get full access to The Claim Game at jeremyzug.substack.com/subscribe

EPISODE SUMMARYIn the world of Revenue Cycle Management (RCM), ignoring your aging report is like planting a garden and never pulling the weeds—eventually, you’ll lose your harvest. Jeremy Zug walks us through the anatomy of an aging report, defining the levels of urgency for claims sitting in 30, 60, and 90-day buckets. We discuss the critical difference between a rejection and a denial, how to calculate your "Days in AR," and why your EHR might be holding your financial health hostage. This episode is all about moving from frustration to traction by treating your AR follow-up like an appointment you’d never cancel. KEYWORDSRevenue Cycle Management, RCM, Aging Report, Days in AR, Claim Denials vs. Rejections, Batching, Timely Filing Limits, Electronic Health Record, EHRTAKEAWAYSKnow Your Buckets: Think of your aging report as a map of urgency. The 31–60 day range is your "Goldilocks zone" for follow-up—not too early to be annoying, but not too late to be ignored. The 90-Day Danger Zone: Anything over 90 days is "where money goes to die." Waiting until a claim hits this mark to check in means you’re likely bumping up against timely filing limits and appeals deadlines. Batching is the Secret to Scaling: Don't chase the oldest claim first. Sort your report by payer and handle 10 claims in one call or portal login. It maximizes efficiency and minimizes your time on hold. Always Get a Receipt: Never end a call with a payer representative without a call reference number. It forces accountability and serves as your "save point" if you have to call back. Consistency Over Intensity: Small weeds are easy to pull; a 90-day forest is a nightmare to clear. Block out dedicated time (at least two hours) weekly to manage your aging. CHAPTERS00:00 Introduction: Why Aging Follow-Up Matters for Your Claims02:36 Breaking Down the Aging Report08:53 Building a System for Aging Claim Follow-Up13:16 Case Study: Solving an $8,000 Aging Claim Problem14:16 Conclusion: Key Takeaways for Managing Aging ClaimsRESOURCESToday Sponsors: Jane | One Month Grace Period Promo Code: PRACTICESOLUTIONS1MOLearn More About The Claim Game: Visit practicesol.com/podcastThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance.Images: Claim Management Spreadsheet Get full access to The Claim Game at jeremyzug.substack.com/subscribe

EPISODE SUMMARYIn this episode, Jeremy Zug takes a strategic pause to interview a true healthcare game changer: Dr. Jeremy Friese, founder and CEO of Humata Health.Dr. Friese isn't just a tech executive; he’s a "recovering Mayo Clinic physician" who spent two decades in the trenches as an interventional radiologist. After witnessing the systemic failures of healthcare during his mother’s battle with cancer, he dedicated his career to fixing the "broken fax machine" of the industry.We dive deep into the world of Prior Authorization—the ultimate bottleneck in patient care. Dr. Friese explains how Humata is using AI to turn administrative friction into a thing of the past, reducing provider burnout and ensuring that "Barb the nurse" can get back to what she does best: caring for patients. We explore the "AI arms race," why payers actually want providers to have better technology, and how the new CMS regulations are acting as a regulatory tailwind for the entire industry.KEYWORDSPrior Authorization, Revenue Cycle Management, Health Tech, AI in Healthcare, Medical Billing, Practice Management, CMS 0057, Provider Burnout, Healthcare InnovationTAKEAWAYSPrior Auth is the Ultimate Bottleneck: It is the "middle of the hourglass" in the revenue cycle. If you don't get the authorization right, you can't deliver care, and you certainly won't get the claim paid. The "Business of Yes": AI isn't just about automation; it's about getting to a "yes" more efficiently. Between 20% and 40% of authorizations submitted are for services that don't even require one—technology can eliminate that wasted effort instantly. The AI Arms Race is a Myth: In the world of prior auth, the opposite is true. Payers actually benefit when providers use advanced technology because it reduces the administrative burden on their end to review manual, 100-page clinical faxes. The "Gray Zone" of Medicine: While AI will likely handle 90% of submissions in the next five years, the "practice of medicine" will always have a gray zone that requires a human expert to interpret complex medical policies. Post-Authorization Monitoring: Life changes in the 30 days between an approval and a surgery. If the CPT code or site of service shifts even slightly, you’ll face a denial on the back end unless you are constantly monitoring that auth status.CHAPTERS00:00 Introduction: Meet the Mind Behind Humata Health04:55 A Decade in Prior Auth: The Problem That Sparked Humata07:24 Why Prior Authorization Needs Both Policy and Technology10:24 The Shared Pain: Bridging Providers and Payers15:14 How It Actually Works: Inside Modern Prior Authorization Tech22:02 The Hardest Part: Extracting Data from EMRs26:49 How Automation Replaces Manual Follow-Ups28:34 After Approval: The Risk of Prior Auth Expiration30:26 Why Humata Wins: Focus, Speed, and a Head Start35:38 Will AI Replace Prior Auth Jobs?39:25 Faster Decisions, Better Care: The Impact of CMS 005741:52 Conclusion: Prior Auth Is Solvable—But You Have to Start NowRESOURCESToday Sponsors: Jane | One Month Grace Period Promo Code: PRACTICESOLUTIONS1MOLearn More About Humata Health: Visit humatahealth.comLearn More About The Claim Game: Visit practicesol.com/podcastThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance. Get full access to The Claim Game at jeremyzug.substack.com/subscribe

EPISODE SUMMARYJeremy explains that accounts receivable is like a treasure chest with two different locks: Payer Aging (insurance) and Patient Aging (people). While insurance is a game of logic and data, patient aging is a game of relationships and communication. We dive into the "90-day mistake"—the friction created when a provider waits too long to bill, leaving patients feeling "ambushed" by a surprise $400 invoice. To fix this, Jeremy outlines the Three Pillars of Collection: a rock-solid financial policy, manual eligibility checks, and keeping a credit card on file. Finally, we walk through a systematic "battle plan" for handling debt in 30, 60, and 90-day buckets. KEYWORDSPatient Aging, Accounts Receivable, Revenue Cycle Management, Financial Policy, Eligibility and Benefits, Credit Card on File, RCMTAKEAWAYSThe Two-Lock Treasure Chest: You cannot treat patient debt the same way you treat Cigna or Aetna. Payer aging requires tenacity; patient aging requires empathy and clear boundaries. The 90-Day Ambush: Waiting too long to collect doesn't make you "nice"—it cracks the clinical relationship. To be clear is to be kind. Stop the Bleeding at Intake: If you get your financial policy, manual eligibility checks, and credit card on file right, your patient AR will likely drop by 80%. Ditch the "Green Checkmark": Never rely solely on your EHR’s automated verification. It won't tell you about specialized carve-outs or $5,000 deductibles that haven't been met. Link Money to Access: For balances over 60 days, move from automated emails to personal outreach. If it hits 90 days, you must be willing to link payment to their spot on your schedule. CHAPTERS00:00 Introduction: The Next Billing Domain—Patient Aging Management03:23 Payer Aging vs. Patient Aging: Two Different Games09:35 The Three Pillars of Patient Collections15:54 How to Handle Aging Patient Balances19:16 Conclusion: Your Patient Aging Game PlanRESOURCESToday Sponsors: Jane | One Month Grace Period Promo Code: PRACTICESOLUTIONS1MOLearn More About The Claim Game: Visit practicesol.com/podcastThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance. Get full access to The Claim Game at jeremyzug.substack.com/subscribe

EPISODE SUMMARYDealing with insurance denials can feel like a special kind of rejection. You’ve done the work, you’ve served your patients, and then—BAM—denied. It’s the healthcare equivalent of a "check engine" light: frustratingly vague but impossible to ignore. In this episode, Jeremy Zug dives into the nitty-gritty of denial resolution, reframing these "no’s" as puzzles waiting to be solved. We’re moving from the investigation phase of aging follow-up into the courtroom drama of winning your money back.Jeremy breaks down the critical difference between a rejection and a denial, the "secret handshake" of Box 22, and how to write an appeal letter that Gary in the insurance cubicle will actually want to approve. If you’re tired of hitting the resubmit button and getting nowhere, this episode is your roadmap to meaningful traction in your billing department.KEYWORDSRevenue Cycle Management, Denial Resolution, Insurance Billing, Private Practice, Medical Billing, Healthcare FinanceTAKEAWAYSRejection vs. Denial: Think of a rejection as being stopped by the bouncer at the door (data errors caught by the clearinghouse). A denial is being kicked out by the bartender after you're already inside (the payer processed the claim but decided not to pay). Stop the "Resubmit" Doom Loop: Simply hitting resubmit on a denied claim without changes is the fastest way to trigger a duplicate claim denial—the #1 denial reason in healthcare. The Magic of Box 22: When correcting a mistake, use Resubmission Code 7 in Box 22 and link it to the original claim number. This "secret handshake" tells the computer you're replacing the old claim, not sending a duplicate. Decoding CARC Codes: Claim Adjustment Reason Codes (like CO-16 or CO-29) are clues. If the code is vague, don’t be afraid to call the representative and make them tell you exactly which "box" is empty. Write "Low-Calorie" Appeals: When the insurance company makes a mistake, your appeal letter should be clear and concise. Highlight the specific sentence in the medical record that proves your case so the reviewer doesn't have to hunt for it. Denial is a Game, Not a Verdict: Don't take it personally. A denial is often just a request for more information or a specific correction within a computer algorithm's rules.CHAPTERS00:00 Introduction: Navigating Aging Follow-Up and Denial Resolution02:27 Why Denials Hurt — and How to Reframe Them05:35 Decoding Denials: Rejections, Reason Codes, and What to Do Next12:51 Fix It or Fight It: How to Handle a Denial Correctly16:55 Why Denial Resolution Separates Thriving Practices18:41 Case Study: Turning $900K in Denials Into Revenue20:11 Conclusion: Tools, Takeaways, and What’s NextRESOURCESToday Sponsors: Jane | One Month Grace Period Promo Code: PRACTICESOLUTIONS1MOLearn More About The Claim Game: Visit practicesol.com/podcastThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance.Images: Appeals Packet, Denial Resolution Guide, Claim Management Spreadsheet Get full access to The Claim Game at jeremyzug.substack.com/subscribe

EPISODE SUMMARYIs your practice running like a high-performing business, or is it just surviving from one grant cycle to the next? In this episode of The Claim Game, Jeremy and Kathryn Zug sit down with Jill Steeley, a powerhouse in community health and former CEO of PureView Health Center. Jill shares the incredible story of how she walked into an organization facing a nearly $1 million deficit and transformed it into a thriving center with $5 million in cash reserves, all while doubling patient count and growing revenue fivefold. Jill breaks down her "business-first" philosophy for FQHCs, the five-step approach to organizational transformation, and why the "no margin, no mission" mindset is the key to sustainable patient care. Whether you are leading a large community health center or a small private practice, Jill’s insights on diversifying revenue, fixing "leaky" costs, and the power of professional rebranding are game-changers for any healthcare leader.KEYWORDSFQHC, Revenue Cycle Management, Healthcare Leadership, Practice Management, Community Health, Medical Billing, Patience Experience, Healthcare Marketing, AI in HealthcareTAKEAWAYSRun it Like a Business: Public and community health often fall into the trap of "grant dependency." To be sustainable, you must adopt the mindset that a profitable business is the only way to ensure the mission continues. The Five-Step Transformation: Jill and her partner Steve Weinman teach a CEO Bootcamp focusing on:1. Increasing & Diversifying Revenue: Don't just wait for grants; get out into the community and partner with large employers. 2.Reducing Costs (Fixing Leaks): Address the "silent killers" of revenue—no-shows and high staff turnover. 3. Marketing & Branding: If the community thinks you only do travel vaccines or serve a niche population, you are losing patients with payers. 4. Exceptional Patient Experience: Move from "transactional" to "transformational" care to increase patient retention. 5. Maintaining Momentum: Long-term planning ensures you don't "coast" between funding cycles. Invest in Technology Now: Use current funding to invest in AI scribes, automated billing, and better hardware. If your tech is "slow as molasses," your best staff will leave for a practice that respects their time. Control What You Can Control: You cannot control federal grant cycles or Medicaid eligibility changes, but you can control your payer mix, your brand, and your operational excellence. CHAPTERS00:00 Introduction: Meet Jill Steeley05:38 Facing the Reality: A Health Center in Crisis07:52 Transforming a health center from a $1 million deficit to reserves07:55 The Business Playbook for an FQHC Turnaround11:53 A Five-Step Playbook for Health Center Transformation24:50 From Grant Dependence to Financial Sustainability31:17 How FQHCs Can Attract Privately Insured Patients34:19 The Role of AI in Healthcare Administration40:16 Why Health Centers Need Better Data Tracking43:27 Conclusion: Preparing Health Centers for 2027RESOURCESToday Sponsors: Jane | One Month Grace Period Promo Code: PRACTICESOLUTIONS1MOFREE WEBINAR: Why Dwindling Grant Money & Government Dysfunction Might Be the Best Thing That's Ever Happened to Your Health Center | Friday 3/13/26 3pm ESTLearn More About The Claim Game: Visit practicesol.com/podcastThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance. Get full access to The Claim Game at jeremyzug.substack.com/subscribe

EPISODE SUMMARYEver feel like you’re playing a game of "Red Light, Green Light" with insurance companies, only the light is always stuck on red? We sat down with a true healthcare game changer, Amy Turner, Deputy Director for Policy at the CMS Innovation Center (CMMI), to talk about how they are trying to fix that.Amy breaks down the mission of CMMI—lowering costs while boosting quality—and introduces us to the WISeR model. This isn't just bureaucratic talk; it’s a look at how advanced technology and the "Kennedy Pledge" are aiming to turn prior authorizations from a provider nightmare into a streamlined, transparent process—maybe even reaching the "holy grail" of auto-approvals. We also dive into the three pillars of innovation: more preventive care, empowering patients with actionable info, and boosting competition for independent physicians.KEYWORDSCMMI, WISeR Model, The Kennedy Pledge, Value-Based Care, Prior Authorization, MedicareTAKEAWAYSSustainability is the Goal: Healthcare costs are outpacing inflation and GDP, yet outcomes aren't keeping up. CMMI's mission is to find the "mother load": reducing costs while improving quality.The Three Strategic Pillars:1. Preventive Care: Nipping health issues in the bud before they become serious.2.Consumer Empowerment: Giving patients digestible, actionable information so they can make informed choices.3. Choice and Competition: Specifically empowering independent physicians and bringing more options to rural areas.Prior Auth Modernization: The WISeR model aims to use technology to create consistent, timely decisions. The ultimate goal is to reach a point of auto-approvals based on proven accuracy.Stewardship of Funds: Everything the Innovation Center does is built on being careful stewards of taxpayer money (Medicare and Medicaid).CHAPTERS00:00 Introduction: Inside CMMI and the WISeR Model07:13 How WISeR Improves Patient Safety11:03 How WISeR Is Tested and Evaluated14:34 Where WISeR Is Launching and What It Covers16:24 How WISeR Uses Technology Responsibly22:46 Measuring WISeR’s Long-Term Impact24:29 Conclusion: Staying Updated on WISeRRESOURCESToday Sponsors: Jane | One Month Grace Period Promo Code: PRACTICESOLUTIONS1MOLearn more about WISeR: Visit https://www.cms.gov/priorities/innovation/innovation-models/wiserLearn More About The Claim Game: Visit practicesol.com/podcastThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance. Get full access to The Claim Game at jeremyzug.substack.com/subscribe

EPISODE SUMMARYIs your practice’s revenue stuck in "limbo"? You do the work, you see the patients, you submit the claims—and then... silence. No check, no deposit, just a line item on a spreadsheet getting older by the second.In this episode of The Claim Game, Jeremy Zug dives into what is arguably the most intimidating territory in the entire revenue cycle: Aging Follow-Up. Jeremy demystifies the aging report, moving it out of the "box of shame" and into a manageable process. We discuss why time is the enemy (claims don't age like fine wine—they rot!), how to triage your buckets, and the exact three-step strategy to work your reports efficiently without losing your mind to elevator hold music.Don't let the insurance companies keep your hard-earned money just because they're better at "hide-and-seek" than you are. It’s time to clear out the weeds in your financial garden and get your cash flow blooming again.KEYWORDSRevenue Cycle Management, Aging Report, Private Practice, Medical Billing, Insurance Denials, Timely Filing, Cash Flow, Practice GrowthTAKEAWAYSThe Aging Report is a Garden: Think of your claims as seeds. Some are blooming, but others are being choked out by weeds. Your aging report is the truth-teller that shows you which plants need immediate water before they wither away.Time is Your Enemy: Claims do not get better with age. Every payer has a Timely Filing deadline. If you wait too long to ask for your check, the insurance company essentially gets "free therapy" while you lose the right to collect that money entirely.Triage Your Buckets: * 0–30 Days: Fresh seeds, usually just processing.31–60 Days: A yellow flag; something might have stalled.90+ Days: The danger zone. These need immediate attention before they hit the filing limit.Stop the "Ostrich Strategy": Freezing and ignoring the report won't make the "check engine light" go away. Treat your aging report like dirty laundry—don't cry over it, just put it through the cycle one piece at a time.Efficiency Over Alphabetical: Never work your report A–Z. Instead:1. Sort by Payer: Resolve multiple claims in one phone call.2. Sort by Age: Save the claims closest to expiring first.3. Sort by Dollar Amount: Prioritize high-value claims for a better ROI on your time.Get the Receipts: Always ask for a Call Reference Number. If you don't document the call, the insurance company can "erase your reality" when the check doesn't show up.CHAPTERS00:00 Introduction: Understanding Aging Follow-Up and Why It Matters05:50 What an Aging Report Is (and Why Time Matters)11:35 The Psychology of the Aging Report14:16 A Three-Step System for Tackling Aging18:20 Conclusion: Building a Sustainable Aging WorkflowRESOURCESToday Sponsors: Jane | One Month Grace Period Promo Code: PRACTICESOLUTIONS1MOLearn More About The Claim Game: Visit practicesol.com/podcastThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance.Images: Denial Resolution Guide, Claim Management Spreadsheet, Appeals Packet Get full access to The Claim Game at jeremyzug.substack.com/subscribe

EPISODE SUMMARYIs your practice’s bank balance giving you a false sense of security? In this episode, Jeremy Zug moves the game piece into the territory of Payment Posting. While it might sound as exciting as watching paint dry, Jeremy breaks down why this "menial chore" is actually the scorecard for your entire practice. We’re moving from the dopamine hit of seeing money in the bank to the precision of knowing why it's there.Jeremy dives into the three critical KPIs you need to track today to ensure you aren't "guessing" with your finances or accidentally billing your patients "ghost money." If you want to know if you're actually winning the game or just slowly bleeding out, this episode is your diagnostic check-up.KEYWORDSRevenue Cycle Management (RCM), Payment Posting, Key Performance Indicators (KPIs), Claim Denials, Electronic Remittance Advice (ERA), Explanation of Benefits (EOB), Timely Filing, Practice Health Check, Mental Health BillingTAKEAWAYSThe Bank Balance Trap: Seeing a deposit is great, but if you don't know if it matches your contract, you aren't winning; you're guessing. Time to Post (The Speed Score): Don't drive with a delayed GPS. If your posting lags, your aging reports become fiction, leading to wasted hours calling insurance companies for money they've already sent. Payment Posting Accuracy (The Precision Score): Use a simple pass-fail audit. Even a one-cent variance is a fail. Precision prevents "ghost money" errors that destroy patient trust. Days to Denial Discovery (The Friction Score): This is the ticking bomb. You have to find denials before the "timely filing" clock runs out, or that revenue is gone forever. The Power of Auditing: Tracking these metrics is like checking your blood pressure; it's the only way to prevent a financial "heart attack" down the road.CHAPTERS00:00 Introduction: Advancing the Game Board — Payment Posting KPIs02:37 Playing Blindfolded: Why KPIs Matter05:27 KPI #1: Time to Post Payments07:45 KPI #2: Payment Posting Accuracy11:22 KPI #3: Average Days to Denial Discovery13:41 Case Study: One Million Dollars in Preventable Denials15:18 Conclusion: Stop Guessing, Start TrackingRESOURCESToday Sponsors: Jane | One Month Grace Period Promo Code: PRACTICESOLUTIONS1MOLearn More About The Claim Game: Visit practicesol.com/podcastThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance.Images: Payment Posting KPI Dashboard Get full access to The Claim Game at jeremyzug.substack.com/subscribe

EPISODE SUMMARYIn this episode, Jeremy breaks down the critical distinction between your Billed Amount (your "sticker price") and the Allowed Amount (the "club member price" you negotiated in your contract). Using the story of "Sarah," a clinician frustrated by receiving $112.50 for a $180 session, Jeremy explains the "Lesser of Two" rule. You’ll learn why setting your fees too low prevents you from capturing automatic raises when insurance companies update their rates, and why your fee schedule needs to be a "bucket" big enough to catch every drop of revenue available.KEYWORDSRevenue Cycle Management, Allowed Amount, Billed Amount, Contractual Adjustment, Lesser of Two Rule, Balance Billing, Fee ScheduleTAKEAWAYSThe "Lesser of Two" Rule: Insurance computers are programmed to pay the lower of two numbers: their internal fee schedule or your billed amount. If you lower your price to match them, you'll miss out on future rate increases. The "Bucket" Analogy: Think of your billed amount as a bucket. If the insurance company wants to pour $115 into a $112 bucket, that extra $3 spills over the side and is lost forever. Strategic Fee Setting: We generally recommend setting your fee schedule at 150% to 200% of the Medicare rate in your area to ensure you aren't undercutting yourself on better-paying commercial contracts. Stop Balance Billing: The difference between your billed rate and the allowed amount is a "contractual adjustment." You are legally obligated to write this off—trying to collect it from the patient is a fast track to getting kicked out of the network. Know Your Data: You can find your allowed amounts through portal hunts, direct calls to provider relations, or by reviewing your last five paid claims. CHAPTERS00:00 Introduction: Zooming In on Billing Domain Strategies02:46 Understanding Allowed Amounts and Fee Schedules12:27 How to Look Up Insurance Allowed Amounts16:30 Payment Posting and Claim Tracking Essentials18:31 Conclusion: One Simple Check to Maximize RevenueRESOURCESToday Sponsors: Jane | One Month Grace Period Promo Code: PRACTICESOLUTIONS1MOLearn More About The Claim Game: Visit practicesol.com/podcastThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance.Images: Claim Management Spreadsheet, Payment Posting Guide Get full access to The Claim Game at jeremyzug.substack.com/subscribe

EPISODE SUMMARYEver opened your EHR expecting a paycheck only to find a big fat zero staring back at you? It feels like adding insult to injury—you’ve done the credentialing, nailed the notes, and submitted everything on time, yet you’re left with nothing but frustration. In this episode of The Claim Game, Jeremy Zug dives into the most dreaded part of the revenue cycle: denials. Instead of treating a denial like a dead end or a failure, Jeremy re-frames it as a "treasure map" full of clues. We explore why physically recording every denial is the anchor to your practice's financial health and how to use the right "Rosetta Stone" to decode the secret language insurance companies use to keep your money.KEYWORDSRevenue Cycle Management, Insurance Denials, Private Practice, Medical Billing, Credentialing, EOB, Patient Care, Practice Growth, Mental Health BillingTAKEAWAYSDenials are Data, Not Defeat: A zero-dollar payment isn't a dead end; it's a symptom that helps you diagnose and cure "diseases" in your intake or billing processes. The Danger of "Ghost Money": Failing to post denials inflates your Accounts Receivable (A/R), leading to hiring or purchasing decisions based on money that isn't actually coming. Respect the Appeal Clock: If you don't record the denial date, you might miss the 90-day or 6-month window to legally appeal and rectify the issue. Decode the "Alphabet Soup": To win, you must read both the CARC (the headline/reason) and the RARC (the article/details) to understand exactly what went wrong. Know Who Owes the Money: Group codes like CO (Contractual Obligation) and PR (Patient Responsibility) tell you if you need to write it off or bill the patient—getting this wrong can break patient trust or even the law.CHAPTERS00:00 Introduction: The Hidden Information in a Zero-Payment Claim04:55 Why Zero-Dollar Payments Must Be Posted08:39 Learning the Language of CARCs and RARCs12:55 Group Codes and Legal Responsibility14:57 Documenting Denials the Right Way17:08 Case Study: Solving a $2,000-a-Month Denial Problem18:31 Conclusion: Turning Denials Into Forward MotionRESOURCESToday Sponsors: BlueprintLearn More About The Claim Game: Visit practicesol.com/podcastThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance.Images: Claim Management Spreadsheet, Payment Posting Guide Get full access to The Claim Game at jeremyzug.substack.com/subscribe

EPISODE SUMMARYJeremy breaks down the critical distinction between an EOB (what the patient sees) and a Remittance Advice (the professional version for the provider). He walks through the "detective work" required to audit these documents, highlighting why the Allowed Amount—not just the paid amount—is the number that determines if you’re being underpaid. The episode also explores the "digital pipeline," comparing the speed of ERAs to the "snail mail" of paper and warning about the hidden dangers of "set-and-forget" auto-posting. Finally, Jeremy shares a real-world case study where forensic remittance auditing recovered significant underpayments for a large agency. KEYWORDSRevenue Cycle Management, RCM, Remittance Advice, Explanation of Benefits, EOB, Electronic Remittance Advice, ERA, 835 File, Contractual Obligation, CO Codes, Patient Responsibility, Payer PortalsTAKEAWAYSThe Remittance as a Scorecard: A deposit without a remittance is like a box without a packing slip; you can’t post the money accurately without knowing the patient, date of service, and CPT code. The Trap of the "Paid Amount": Never stop at the paid amount. You must audit the contractual adjustments (CO codes) and patient responsibility (PR codes) to ensure you aren't writing off money you should have collected. ERAs vs. EOBs: Electronic Remittance Advice (ERA) files (835 files) arrive days or weeks faster than paper. However, always look for the PLB segment (provider level adjustments) to find "missing" money buried in recoupments. Portals are a Fast Pass: Use payer portals like Availity or Optum to skip the 45-minute hold times. Portals allow for instant remittance downloads and "correction speed" for fixing claim modifiers in days rather than months.CHAPTERS00:00 Introduction: Making Sense of Remittances and Portals02:48 Remittance vs. EOB: Knowing the Difference06:48 From Paper to Digital: Understanding ERAs09:56 The Secret Weapon: Payer Portals12:20 Case Study: Finding Hidden Underpayments15:47 Conclusion: The Winning Formula for Remittances and PortalsRESOURCESToday Sponsors: BlueprintLearn More About The Claim Game: Visit practicesol.com/podcastThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance.Images: Guide to the Components of an EOB, Guide to the Components of an ERA Get full access to The Claim Game at jeremyzug.substack.com/subscribe

EPISODE SUMMARYJeremy and Dr. Dylan Ross explore the "back door" of managed healthcare, tracing Dylan's journey from direct care delivery to the high-level strategic world of major payers. They dive deep into the current "recalibration" of behavioral health—where stigma is eroding and utilization is up, but the backend business models are struggling to keep pace. Dylan explains why payers are often "blind" to whether patients are actually getting better and how Measurement-Based Care (MBC) is the key to unlocking better reimbursement and clinical outcomes. They also discuss how AI scribing and a reimagined EHR are helping independent practices fight back against administrative burnout.KEYWORDSMeasurement-Based Care (MBC), Revenue Cycle Management (RCM), AI Scribing, Value-Based Care, Clinician Burnout, Outcome Data, Behavioral Health InnovationTAKEAWAYSThe Data Gap in RCM: Unlike physical health, where "vital signs" like blood pressure are standard, behavioral health has historically lacked a lab-equivalent data point. The Power of Measurement-Based Care: Aggregating patient-reported outcome data doesn't just help the clinical dyad; it allows practices to "tier" their value to payers and secure better contracts. Fighting the "Tyranny of the Urgent": Administrative tasks, documentation, and fighting clawbacks are eating the "widget" of healthcare: Time. AI as a Clinical Ally: Modern tools like Blueprint's AI scribe are saving clinicians 7–10 hours per week, allowing them to focus on high-quality care rather than staring at a screen. Reimagining the EHR: Most current systems were built for physical health and "duct-taped" together for therapists. The future is a bottoms-up EHR built specifically for the behavioral health workflow. CHAPTERS00:00 Introduction: Dr. Dylan Ross and the Systems Behind Behavioral Health12:03 Navigating the Healthcare Landscape: Insights from Experience23:48 Reality Checks in the Insurance Industry30:24 The Data Gap Holding Back Value-Based Behavioral Health35:17 How Blueprint Is Changing Measurement in Private Practice39:33 Above the Red Line: Where Measurement-Based Care Actually Happens46:21 The Future of Blueprint and EHR Innovations56:27 Conclusion: Using Technology to Reclaim Time, Purpose, and AutonomyRESOURCESToday Sponsors: BlueprintLearn More About The Claim Game: Visit practicesol.com/podcastThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance. Get full access to The Claim Game at jeremyzug.substack.com/subscribe

EPISODE SUMMARYJeremy introduces the fourth billing domain, Payment Posting, and explains why it must follow eligibility and benefits. He defines posting as the reconciliation of your expectations (contracts and CPT codes) versus reality (what the payer actually sends). The episode covers the four macro-moves of the territory: Receipt, Posting, Denial Capture, and KPIs. You'll learn the difference between paper EOBs and electronic ERAs, the dangers of "bucket posting," and why a zero-dollar payment is one of the most important transactions you’ll ever document.KEYWORDSEOB, CARC, ERA, Payment Posting, Private Practice, Insurance Billing, Medical Billing, Eligibility and Benefits, Insurance Denials, Claim DenialsTAKEAWAYSMove Beyond "Monopoly Money": Don't just high-five when money hits the bank. Without meticulous posting, you might only be collecting 60-85% of what you're actually owed. Line-Item Posting is King: Avoid "bucket posting" (lump sums). Matching payments to specific dates of service and CPT codes ensures clean data and prevents missed appeal opportunities. Zero Dollars is Still a Transaction: When a payer sends a $0.00 remittance, it’s not an invitation to move on. It’s a signal to document the specific CARC (Claim Adjustment Reason Code) to prevent the "tangled ball of yarn" that is unresolved A/R. Watch Your KPIs: Aim for a Net Collection Rate of 95% or higher and a First Pass Denial Rate of less than 5%. If your days-to-post exceeds two weeks, your financial reports are essentially a lie.CHAPTERS00:00 Introduction: Setting the Stage for Payment Posting05:17 Payment Posting Defined: The Scoreboard of Billing07:38 The Four Moves That Make Payment Posting Work11:32 The Payment Posting Workflow: Intake to Line Items15:47 The Payment Posting Workflow: Denial Documentation19:38 The Payment Posting Workflow: KPIs22:10 Case Study: Recovering $78,000 in Lost Receivables24:24 Conclusion: Mastering the Payment Posting GameRESOURCESToday Sponsors: BlueprintLearn More About The Claim Game: Visit practicesol.com/podcastThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance. Get full access to The Claim Game at jeremyzug.substack.com/subscribe

EPISODE SUMMARYIn this domain-specific deep dive, Jeremy explains why tracking metrics for eligibility and benefits (E&B) is the secret weapon of a proactive practice. Many providers view E&B as a "time suck," but without clear KPIs, you’re flying blind. Jeremy breaks down three essential metrics—Time to Completion, Accuracy Rate, and Call Time Logs—to help you identify which payers are dragging their feet and which staff members might need a little extra support. The goal is simple: ensure your patients never walk through the door without knowing exactly what they owe, preserving both your trust and your bottom line. KEYWORDS​​Revenue Cycle Management, Private Practice, Medical Billing, Insurance Eligibility, Practice Management, KPIs, Patient Trust, Healthcare FinanceTAKEAWAYSThe Cost of Lost Trust: When a patient receives an unexpected bill, trust leaves your practice, and revenue usually follows right behind it. Move from Reactive to Proactive: Tracking metrics helps you catch "carve-outs" (where a payer subcontracts benefits) before they turn into denials downstream. Efficiency vs. Accuracy: It’s not just about how fast you do it; it’s about getting the right information the first time so your billing team isn't ripping their hair out later. Identify Payers of Concern: Use data to decide if a specific insurance company’s low reimbursement rate is worth the administrative headache of their "Byzantine" phone systems. The Power of Time Studies: Tracking call times for just two weeks can reveal which payers offer efficient portals and which ones are wasting your staff’s time. CHAPTERS00:00 Introduction: Protecting Patient Trust Through Better Eligibility Metrics03:42 Managing Time and Cost Through Eligibility Metrics06:36 Key Performance Indicators for Eligibility and Benefits13:50 The Trust Metric: Measuring Eligibility & Benefits Accuracy17:24 The Final KPI: Eligibility & Benefits Call Time19:36 The Eligibility & Benefit KPI Dashboard20:53 Conclusion: Building a Stronger Revenue Cycle Through MetricsRESOURCESToday Sponsors: BlueprintLearn More About The Claim Game: Visit practicesol.com/podcastThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance.Images: Eligibility & Benefit KPI Dashboard Get full access to The Claim Game at jeremyzug.substack.com/subscribe

EPISODE SUMMARYEver felt like you were crushing a game of Monopoly or Catan, only to have one bad card flip the entire board? In the world of private practice, Eligibility and Benefits (E&B) often feels exactly like that. You think your revenue is secure, and then—BAM—a missed rule or a shift in patient benefits leaves you disoriented and losing ground. In this episode of The Claim Game, Jeremy Zug dives deep into two "hidden" steps that often trip up even the best practices: updating accumulations and preventative patient communication. We’re moving beyond the one-time snapshot and looking at how to track the moving target of deductibles and out-of-pocket maximums. Whether you’re a solo provider or managing a large agency, mastering these domains is the only way to turn your billing system into a revenue engine rather than a drain on your mission. KEYWORDSRevenue Cycle Management, Eligibility and Benefits, Private Practice, Patient Communication, Medical Billing, Deductibles, Cash FlowTAKEAWAYSE&B is a Snapshot, Not a Guarantee: An eligibility check is only accurate for the 15-minute window in which you looked; it is a quote, not a promise of payment. The Power of Accumulations: Patients rack up healthcare costs across multiple specialties throughout the year. If you aren't regularly updating their "accumulation" (how close they are to meeting their deductible), you risk overcharging them—which leads to messy refunds—or undercharging them, which makes collections nearly impossible once they leave the office. To Be Clear is to Be Kind: Preventative communication is the bedrock of patient trust. Surprising a patient with a $4,000 bill on the day of their appointment is a "trust-degrader" that can lead to abandoned care and a damaged reputation. Use the Right Tools: Don't reinvent the wheel. Using standardized E&B templates and benefit summary emails ensures your front office, clinicians, and patients are on the same page every single time. Process Over Magic Bullets: As shown in our Pennsylvania agency case study, injecting repeatable SOPs and clear communication into a fragmented system reduces aging AR and increases both patient and clinician satisfaction. CHAPTERS00:00 Introduction: Zooming In on Eligibility02:12 Why Eligibility Isn’t a One-Time Check04:59 Understanding and Managing Patient Accumulations08:45 Communicating Financial Responsibility to Patients12:42 The Consequences of Not Communicating Costs Upfront14:02 Using Templates to Fix Accumulations and Communication Gaps16:05 Case Study: How One Practice Recovered from Eligibility Breakdown17:43 Conclusion: How to Protect Trust and Revenue with Better EligibilityRESOURCESToday Sponsors: BlueprintLearn More About The Claim Game: Visit practicesol.com/podcastThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance.Images: Benefit Stages, Benefit Summary Email Template, Eligibility & Benefit Check Template Get full access to The Claim Game at jeremyzug.substack.com/subscribe

EPISODE SUMMARYPrior authorization (PA) is the boss level of the Eligibility & Benefits domain, the giant locked door that stands between you and getting paid. This week, Jeremy is diving deep into the controversial world of prior authorizations, debunking the persistent myth of the "retro auth" and breaking down exactly how to conquer this gatekeeper of revenue.We walk you through the three crucial hurdles: Identification, ensuring you know the requirements before the patient walks in; Request, mastering the art of over-communicating medical necessity to avoid the "delay loop" ; and the Outcome—including how to sidestep the exhausting peer-to-peer review trap.We also zoom out to the massive national conversation happening right now—patient access vs. cost containment—and discuss the "gold carding" trend that could revolutionize how good providers play the game. Learn the two essential tools you need to turn PA chaos into efficiency and ensure your hard work translates into deposits, not denials.It's time to build a bulletproof process and win The Claim Game as it's played today.KEYWORDSPrior Authorization, Revenue Cycle Management, RCM, Insurance Billing, Claim Denials, Medical Necessity, Retro Authorization, Gold Carding, Private Practice, Practice Management,  The Claim GameTAKEAWAYSAnticipatory Anxiety is Real: Prior authorization is often the most anxiety-inducing step in RCM, and for good reason—missing this step means you get paid $0 for the work.Identify Early: Prior authorization is a permission slip that must be secured before the service is rendered. Use the intake call and your E&B check to identify if an auth is required for the specific CPT code or service.Over-Communicate Medical Necessity: Avoid the time-sucking peer-to-peer review trap by making your initial submission bulletproof. Use the payer’s language: detail specific symptoms, measurable goals, and evidence-based treatment.Retro-Auth is a Myth: Do not build your practice on the "hail Mary pass" of hoping for a retroactive authorization. The best strategy is pre-authorization. If the denial is due to your administrative error, you will usually have to eat the cost.Track the Count, Don't Blow the Meter: Authorization numbers are not a one-stop gate; they are a meter. Use a countdown mechanism (like one in your EHR) to flag when you hit session eight out of ten. This prevents revenue loss and, most importantly, avoids disrupting your client's necessary care.Essential Tools for Success: You need two pieces of equipment: a dedicated Prior Authorization Checklist(tracking dates, reference number, stipulations, and expiration) and an updated Insurance Contact Reference List with a tab specifically for authorization requirements.CHAPTERS00:00 Introduction: Entering the Prior Authorization Gate04:03 The Three Hurdles of Prior Authorization11:15 Access vs. Cost: The Prior Authorization Battle16:01 The Myth of Retro Authorization18:11 The Tools You Need to Master Prior Authorization20:46 Case Study: The Importance of Tracking Authorizations22:53 Conclusion: Winning the Prior Authorization GameRESOURCESToday Sponsors: BlueprintLearn More About The Claim Game: Visit practicesol.com/podcastThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance.Images: Prior Authorization Checklist, Insurance Contact Reference List Get full access to The Claim Game at jeremyzug.substack.com/subscribe

EPISODE SUMMARYIs your practice tired of wrestling with insurance denials? In this episode, Jeremy Zug flies solo to dive into the crucial third stage of the Revenue Cycle Management (RCM) Game Board: Eligibility and Benefits (E&B). Jeremy breaks down a two-step, methodical strategy designed to drastically cut down your denial rate and eliminate costly billing surprises. Learn why checking E&B is like reading a rule book before a major journey , and discover the key information to collect to ensure you get paid for the incredible value you add. It’s time to stop walking blind into more denials and start winning The Claim GameKEYWORDS​​Revenue Cycle Management (RCM), Eligibility and Benefits (E&B), Claim Denials, Prior Authorization, Payer Contacts, CPT Codes, Credentialing, Cash Flow, Practice Management, Practice Solutions, The Claim Game, Billing Surprises, Availity, Clean Claims, DocumentationTAKEAWAYS​​We’re covering the two foundational steps to master the E&B territory: building your game manual and executing a consistent check.1. Build Your Game Manual (The Centralized Cheat Sheet): Create a central, living database of essential payer-specific information.Contact Information: Secure the direct, current phone numbers for provider relations—not the general patient line. Note the most efficient route for E&B details, whether a provider portal (like Availity) or a direct call.Service List: Maintain a list of CPT codes for all services your practice provides to verify coverage for each patient’s specific plan.Process Ownership: Assign a designated person to keep this "game manual" updated, ensuring the knowledge is tied to a repeatable process, not a single person's memory.2. Make the E&B Check Mandatory (The Execution): This is the real-time verification that happens before the patient walks in. Every check must be identical and thorough, consolidated onto a standardized template.Core Data: Collect and confirm the patient’s full name, date of birth, and subscriber ID—using objective sources like a copy of the insurance card (front and back) and driver’s license.Required Checks: It's not just a yes/no active status. You need to confirm active coverage, provider match (NPI coverage) , CPT code coverage , telehealth coverage , and any prior authorization or referral requirements.Document Everything: To have "fighting power" against incorrect denials, always secure a date, the payer rep name (if you called), and a reference number for every verification call. This paper trail is your best defense.CHAPTERS00:00 Introduction: Your Two-Step Strategy to Cut Denials02:55 Creating Your Payer Playbook: Contacts, Codes & Clear Ownership07:36 The Payoff: How E&B Checks Keep Your Claims Alive09:01 The E&B Checklist: Verifying Coverage Before the First Session12:02 The E&B Defense Strategy: What Happens When You Don’t Get It Right15:37 Case Study: When Missing Steps Cost Thousands18:09 Conclusion: The Foundations for a Strong, Repeatable E&B ProcessRESOURCESToday Sponsors: BlueprintLearn More About The Claim Game: Visit practicesol.com/podcastThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance.Images: Eligibility & Benefit Check Template, Insurance Contact Reference List Get full access to The Claim Game at jeremyzug.substack.com/subscribe

EPISODE SUMMARYHost Jeremy Zug welcomes Practice Solutions' Billing Director, Kelley Sonnenberg, to dive deep into a core RCM challenge: Insurance Eligibility and Benefits (E&B) verification. This episode cuts through the confusion, addressing the controversial question of who is ultimately responsible for E&B checks (patient or practice?) and the reliability (or lack thereof) of these checks (they're only about 70% accurate!).Kelley, with her extensive experience leading a team of over 20 billers, provides actionable, expert advice on:Handling the 30% Inaccuracy Rate: What to do when an E&B check fails.Common Errors: The biggest mistake providers make (it's confusing different plan types!).Carve Outs: The confusing reality of having a health plan (e.g., Blue Cross Blue Shield) that subcontracts mental health benefits to another company (e.g., Magellan).The Power of Process: The critical need for Standard Operating Procedures (SOPs) and using E&B templates to stop building jobs around people.Advanced Topics: How to handle the Authorization Game Over moment and the key to understanding Coordination of Benefits (COB), including the "Birthday Rule".Simplified Patient Communication: Kelley’s brilliant, three-level "game" analogy for explaining complex terms like deductible, copay, and out-of-pocket maximum to your patients.Ultimately, this episode empowers you to build the solid systems and foundation needed for scalability, making your practice function around process, not just people.KEYWORDSInsurance Billing, Revenue Cycle Management (RCM),  Eligibility and Benefits, EB Verification, Practice Management, Clean Claims, Prior Authorization, Claim Denials, Coordination of Benefits (COB), Carve Outs, Standard Operating Procedures (SOP)TAKEAWAYSE&B is a Practice Safeguard: While the patient is ultimately responsible for knowing their benefits, running an eligibility check is best practice and acts as a crucial safeguard for your practice to ensure clean claim reimbursement and prevent lost revenue from inactive plans.Don't Trust the EHR Tool (Go to the Source): E&B tools built into EHRs are often confusing, can be inaccurate (not real-time), and pull pages of information that are hard to interpret. Always utilize the payer-specific portal (like Availity or Cigna's portal) for the most accurate and easy-to-read, specialty-specific information.The Single Most Impactful Action: Implement a benefit template to standardize your process. This ensures that every check is thorough, covering the effective date, termination date, cost-sharing amounts, session limits, and the most critical item: Authorization requirements.The Game Over Move: Authorization: If a patient requires prior authorization (especially for testing) and you don't get it, it will likely lead to a claim denial that cannot typically be overturned or retroactively authorized, meaning you lose the payment. A PCP referral is not the same as an authorization.Collect the Back of the Card: Always obtain the front and back of the patient’s insurance card. The back of the card has the direct provider phone number for mental health/benefits, which is the quickest way to verify information and uncover carve outs.COB and the Birthday Rule: Coordination of Benefits (COB) denials are common, especially in Q1. The general rule for dependent children is the Birthday Rule: the parent whose birth month comes first in the year has the primary insurance.CHAPTERS00:00 Introduction: Kelley’s Journey to Practice Solutions04:19 Who Should Check Benefits—Practice or Patient?06:59 Eligibility Checks Aren’t a Guarantee08:54 The Most Common Eligibility Mistake12:47 EHR vs. Payer Portals: Where to Trust Your Data15:17 How to Talk Insurance With Patients18:10 Eligibility Overhaul: Templates, SOPs & Intake20:52 Open Enrollment Chaos: Preparing for January22:19 Coordination of Benefits 10125:09 Multi-Site Credentialing & Eligibility26:13 How Payer Volume Impacts Eligibility Work28:28 The One Detail You Can’t Miss: Authorization30:30 Eligibility Mastery: Templates, Portals, Patterns31:58 Conclusion: Foundations for Sustainable ExpansionRESOURCESToday Sponsors: BlueprintLearn More About The Claim Game: Visit practicesol.com/podcastThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance. Get full access to The Claim Game at jeremyzug.substack.com/subscribe

EPISODE SUMMARYIn this essential episode (with Jeremy flying solo as Kathryn welcomes their third child!), we tackle the critical third territory on the RCM Game Board: Eligibility and Benefits Verification. Think of E&B as your practice's scouting phase. We break down exactly what E&B means, why it’s a non-negotiable step before any claim is mentioned , and how mastering this repeatable five-step workflow is the key to preventing those costly, frustrating surprises for both you and your patients. We’ll dive deep into:The two crucial parts of E&B: checking eligibility (is the policy active with me?) and benefits (what does the patient owe?).The nightmare of Prior Authorization (PA) and why correctly checking for this requirement is the punchline to avoiding guaranteed denials.The non-negotiable conversation with your patient about their financial responsibility—the game-changer that builds trust and prevents billing surprises.A real-world case study of a group practice that lost over $20,000 in two months because they missed this crucial step (and how they recovered).This is all part of a sound practice management strategy, ultimately letting you claim victory for your bottom line. It's time to stop the claim denials and turn them into deposits.KEYWORDSRevenue Cycle Management, RCM, Insurance Billing, Private Practice, Practice Management, Eligibility and Benefits, Prior Authorization,  Claim Denials, Patient Care, Cash FlowTAKEAWAYSE&B is the Cornerstone: Eligibility and Benefits verification is the third step and a cornerstone of the entire front-end RCM process. It must happen before there is even mention of a claim.The Two Checks: Eligibility is scouting to confirm the policy is active and you are In-Network. Benefits is determining the cost-sharing responsibilities (deductible, copay, coinsurance, out-of-pocket maximum).PA is the Payment Key: A required Prior Authorization that is not handled correctly guarantees a denied claim. Getting that pre-approval is like getting a special key that unlocks payment.Non-Negotiable Communication: You must clearly explain the patient's financial responsibility before the appointment. This transparency shifts the dynamic from "Why am I getting this bill?" to "Thank you for letting me know what to expect".Repeat the Process: Benefits change all the time! This is not a one-and-done process. Continuously update benefits and benefit verification for accuracy and patient satisfaction.CHAPTERS00:00 Introduction to Revenue Cycle Management01:59 Understanding Eligibility and Benefits Verification05:15 The Workflow of Eligibility and Benefits09:58 Prior Authorization: A Critical Step11:24 Communicating with Patients Effectively13:45 Tools for Managing Eligibility and Benefits16:02 Case Study: The Importance of Verification18:28 Conclusion: Turning Process into PracticeRESOURCESToday Sponsors: BlueprintLearn More About The Claim Game: Visit practicesol.com/podcastThe Hourglass Learning Hub: Dive deeper into RCM best practices and downloadable tools mentioned in this episode, like the various checklists and templates, by visiting The Hourglass Learning Hub.Our Blog: Explore years of educational articles on billing and practice management at Practice Solutions Blog.Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance.Images: Eligibility & Benefits, Insurance Contact Reference List, E&B Template, Benefit Summary Email Template, KPI Dashboard Get full access to The Claim Game at jeremyzug.substack.com/subscribe