Is 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.

KEYWORDS

Private Practice, Revenue Cycle Management, Mental Health Billing, Appalachia, Group Practice Growth, Patient Registration, Medical Billing, Healthcare Business, Credentialing, Therapy Notes, Jane App, AI Notes

TAKEAWAYS

The "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.

CHAPTERS

00:00 Introduction: Meet Brent Metcalf and Tri-Star Counseling

07:33 Why Patient Registration Keeps Slowing You Down

11:37 Improving Intake Through Training and Process

17:48 Culture, Compliance, and Client Experience

22:38 Scaling the Practice: Growth, Real Estate, and Expansion

30:50 Building Community Presence and Referral Networks

32:27 Beyond the Practice: Teaching, Supervision, and Consulting

33:51 Navigating Insurance, Access, and Practice Economics

38:11 Advice for Starting and Scaling a Practice

41:56 Leveraging AI for Notes and Treatment Planning

44:32 Conclusion: Final Insights for Practice Success

RESOURCES

Today Sponsors: Jane | One Month Grace Period Promo Code: PRACTICESOLUTIONS1MO

Learn More About Tri-Star Counseling: tri-starcounseling.com

Upheal: https://upheal.io/join?via=YKWVPJ74

Heard: https://affiliate.joinheard.com/ucv1vp09xwra

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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.

In 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. 

KEYWORDS

Revenue Cycle Management, RCM, Aging Report, Days in AR, Claim Denials vs. Rejections, Batching, Timely Filing Limits, Electronic Health Record, EHR

TAKEAWAYS

Know 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. 

CHAPTERS

00:00 Introduction: Why Aging Follow-Up Matters for Your Claims

02:36 Breaking Down the Aging Report

08:53 Building a System for Aging Claim Follow-Up

13:16 Case Study: Solving an $8,000 Aging Claim Problem

14:16 Conclusion: Key Takeaways for Managing Aging Claims

RESOURCES

Today Sponsors: Jane | One Month Grace Period Promo Code: PRACTICESOLUTIONS1MO

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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

In 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.

KEYWORDS

Prior Authorization, Revenue Cycle Management, Health Tech, AI in Healthcare, Medical Billing, Practice Management, CMS 0057, Provider Burnout, Healthcare Innovation

TAKEAWAYS

Prior 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.

CHAPTERS

00:00 Introduction: Meet the Mind Behind Humata Health

04:55 A Decade in Prior Auth: The Problem That Sparked Humata

07:24 Why Prior Authorization Needs Both Policy and Technology

10:24 The Shared Pain: Bridging Providers and Payers

15:14 How It Actually Works: Inside Modern Prior Authorization Tech

22:02 The Hardest Part: Extracting Data from EMRs

26:49 How Automation Replaces Manual Follow-Ups

28:34 After Approval: The Risk of Prior Auth Expiration

30:26 Why Humata Wins: Focus, Speed, and a Head Start

35:38 Will AI Replace Prior Auth Jobs?

39:25 Faster Decisions, Better Care: The Impact of CMS 0057

41:52 Conclusion: Prior Auth Is Solvable—But You Have to Start Now

RESOURCES

Today Sponsors: Jane | One Month Grace Period Promo Code: PRACTICESOLUTIONS1MO

Learn More About Humata Health: Visit humatahealth.com

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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.

Jeremy 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. 

KEYWORDS

Patient Aging, Accounts Receivable, Revenue Cycle Management, Financial Policy, Eligibility and Benefits, Credit Card on File, RCM

TAKEAWAYS

The 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. 

CHAPTERS

00:00 Introduction: The Next Billing Domain—Patient Aging Management

03:23 Payer Aging vs. Patient Aging: Two Different Games

09:35 The Three Pillars of Patient Collections

15:54 How to Handle Aging Patient Balances

19:16 Conclusion: Your Patient Aging Game Plan

RESOURCES

Today Sponsors: Jane | One Month Grace Period Promo Code: PRACTICESOLUTIONS1MO

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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.

Dealing 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.

KEYWORDS

Revenue Cycle Management, Denial Resolution, Insurance Billing, Private Practice, Medical Billing, Healthcare Finance

TAKEAWAYS

Rejection 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.

CHAPTERS

00:00 Introduction: Navigating Aging Follow-Up and Denial Resolution

02:27 Why Denials Hurt — and How to Reframe Them

05:35 Decoding Denials: Rejections, Reason Codes, and What to Do Next

12:51 Fix It or Fight It: How to Handle a Denial Correctly

16:55 Why Denial Resolution Separates Thriving Practices

18:41 Case Study: Turning $900K in Denials Into Revenue

20:11 Conclusion: Tools, Takeaways, and What’s Next

RESOURCES

Today Sponsors: Jane | One Month Grace Period Promo Code: PRACTICESOLUTIONS1MO

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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

Is 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.

KEYWORDS

FQHC, Revenue Cycle Management, Healthcare Leadership, Practice Management, Community Health, Medical Billing, Patience Experience, Healthcare Marketing, AI in Healthcare

TAKEAWAYS

Run 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. 

CHAPTERS

00:00 Introduction: Meet Jill Steeley

05:38 Facing the Reality: A Health Center in Crisis

07:52 Transforming a health center from a $1 million deficit to reserves

07:55 The Business Playbook for an FQHC Turnaround

11:53 A Five-Step Playbook for Health Center Transformation

24:50 From Grant Dependence to Financial Sustainability

31:17 How FQHCs Can Attract Privately Insured Patients

34:19 The Role of AI in Healthcare Administration

40:16 Why Health Centers Need Better Data Tracking

43:27 Conclusion: Preparing Health Centers for 2027

RESOURCES

Today Sponsors: Jane | One Month Grace Period Promo Code: PRACTICESOLUTIONS1MO

FREE 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 EST

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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.

Ever 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.

KEYWORDS

CMMI, WISeR Model, The Kennedy Pledge, Value-Based Care, Prior Authorization, Medicare

TAKEAWAYS

Sustainability 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).

CHAPTERS

00:00 Introduction: Inside CMMI and the WISeR Model

07:13 How WISeR Improves Patient Safety

11:03 How WISeR Is Tested and Evaluated

14:34 Where WISeR Is Launching and What It Covers

16:24 How WISeR Uses Technology Responsibly

22:46 Measuring WISeR’s Long-Term Impact

24:29 Conclusion: Staying Updated on WISeR

RESOURCES

Today Sponsors: Jane | One Month Grace Period Promo Code: PRACTICESOLUTIONS1MO

Learn more about WISeR: Visit https://www.cms.gov/priorities/innovation/innovation-models/wiser

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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.

Is 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.

KEYWORDS

Revenue Cycle Management, Aging Report, Private Practice, Medical Billing, Insurance Denials, Timely Filing, Cash Flow, Practice Growth

TAKEAWAYS

The 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.

CHAPTERS

00:00 Introduction: Understanding Aging Follow-Up and Why It Matters

05:50 What an Aging Report Is (and Why Time Matters)

11:35 The Psychology of the Aging Report

14:16 A Three-Step System for Tackling Aging

18:20 Conclusion: Building a Sustainable Aging Workflow

RESOURCES

Today Sponsors: Jane | One Month Grace Period Promo Code: PRACTICESOLUTIONS1MO

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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

Is 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.

KEYWORDS

Revenue 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 Billing

TAKEAWAYS

The 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.

CHAPTERS

00:00 Introduction: Advancing the Game Board — Payment Posting KPIs

02:37 Playing Blindfolded: Why KPIs Matter

05:27 KPI #1: Time to Post Payments

07:45 KPI #2: Payment Posting Accuracy

11:22 KPI #3: Average Days to Denial Discovery

13:41 Case Study: One Million Dollars in Preventable Denials

15:18 Conclusion: Stop Guessing, Start Tracking

RESOURCES

Today Sponsors: Jane | One Month Grace Period Promo Code: PRACTICESOLUTIONS1MO

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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

In 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.

KEYWORDS

Revenue Cycle Management, Allowed Amount, Billed Amount, Contractual Adjustment, Lesser of Two Rule, Balance Billing, Fee Schedule

TAKEAWAYS

The "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. 

CHAPTERS

00:00 Introduction: Zooming In on Billing Domain Strategies

02:46 Understanding Allowed Amounts and Fee Schedules

12:27 How to Look Up Insurance Allowed Amounts

16:30 Payment Posting and Claim Tracking Essentials

18:31 Conclusion: One Simple Check to Maximize Revenue

RESOURCES

Today Sponsors: Jane | One Month Grace Period Promo Code: PRACTICESOLUTIONS1MO

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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

Ever 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.

KEYWORDS

Revenue Cycle Management, Insurance Denials, Private Practice, Medical Billing, Credentialing, EOB, Patient Care, Practice Growth, Mental Health Billing

TAKEAWAYS

Denials 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.

CHAPTERS

00:00 Introduction: The Hidden Information in a Zero-Payment Claim

04:55 Why Zero-Dollar Payments Must Be Posted

08:39 Learning the Language of CARCs and RARCs

12:55 Group Codes and Legal Responsibility

14:57 Documenting Denials the Right Way

17:08 Case Study: Solving a $2,000-a-Month Denial Problem

18:31 Conclusion: Turning Denials Into Forward Motion

RESOURCES

Today Sponsors: Blueprint

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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

Jeremy 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. 

KEYWORDS

Revenue Cycle Management, RCM, Remittance Advice, Explanation of Benefits, EOB, Electronic Remittance Advice, ERA, 835 File, Contractual Obligation, CO Codes, Patient Responsibility, Payer Portals

TAKEAWAYS

The 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.

CHAPTERS

00:00 Introduction: Making Sense of Remittances and Portals

02:48 Remittance vs. EOB: Knowing the Difference

06:48 From Paper to Digital: Understanding ERAs

09:56 The Secret Weapon: Payer Portals

12:20 Case Study: Finding Hidden Underpayments

15:47 Conclusion: The Winning Formula for Remittances and Portals

RESOURCES

Today Sponsors: Blueprint

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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

Jeremy 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.

KEYWORDS

Measurement-Based Care (MBC), Revenue Cycle Management (RCM), AI Scribing, Value-Based Care, Clinician Burnout, Outcome Data, Behavioral Health Innovation

TAKEAWAYS

The 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. 

CHAPTERS

00:00 Introduction: Dr. Dylan Ross and the Systems Behind Behavioral Health

12:03 Navigating the Healthcare Landscape: Insights from Experience

23:48 Reality Checks in the Insurance Industry

30:24 The Data Gap Holding Back Value-Based Behavioral Health

35:17 How Blueprint Is Changing Measurement in Private Practice

39:33 Above the Red Line: Where Measurement-Based Care Actually Happens

46:21 The Future of Blueprint and EHR Innovations

56:27 Conclusion: Using Technology to Reclaim Time, Purpose, and Autonomy

RESOURCES

Today Sponsors: Blueprint

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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.

Jeremy 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.

KEYWORDS

EOB, CARC, ERA, Payment Posting, Private Practice, Insurance Billing, Medical Billing, Eligibility and Benefits, Insurance Denials, Claim Denials

TAKEAWAYS

Move 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.

CHAPTERS

00:00 Introduction: Setting the Stage for Payment Posting

05:17 Payment Posting Defined: The Scoreboard of Billing

07:38 The Four Moves That Make Payment Posting Work

11:32 The Payment Posting Workflow: Intake to Line Items

15:47 The Payment Posting Workflow: Denial Documentation

19:38 The Payment Posting Workflow: KPIs

22:10 Case Study: Recovering $78,000 in Lost Receivables

24:24 Conclusion: Mastering the Payment Posting Game

RESOURCES

Today Sponsors: Blueprint

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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.

In 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 Finance

TAKEAWAYS

The 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. 

CHAPTERS

00:00 Introduction: Protecting Patient Trust Through Better Eligibility Metrics

03:42 Managing Time and Cost Through Eligibility Metrics

06:36 Key Performance Indicators for Eligibility and Benefits

13:50 The Trust Metric: Measuring Eligibility & Benefits Accuracy

17:24 The Final KPI: Eligibility & Benefits Call Time

19:36 The Eligibility & Benefit KPI Dashboard

20:53 Conclusion: Building a Stronger Revenue Cycle Through Metrics

RESOURCES

Today Sponsors: Blueprint

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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

Ever 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. 

KEYWORDS

Revenue Cycle Management, Eligibility and Benefits, Private Practice, Patient Communication, Medical Billing, Deductibles, Cash Flow

TAKEAWAYS

E&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.

CHAPTERS

00:00 Introduction: Zooming In on Eligibility

02:12 Why Eligibility Isn’t a One-Time Check

04:59 Understanding and Managing Patient Accumulations

08:45 Communicating Financial Responsibility to Patients

12:42 The Consequences of Not Communicating Costs Upfront

14:02 Using Templates to Fix Accumulations and Communication Gaps

16:05 Case Study: How One Practice Recovered from Eligibility Breakdown

17:43 Conclusion: How to Protect Trust and Revenue with Better Eligibility

RESOURCES

Today Sponsors: Blueprint

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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

Prior 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.

KEYWORDS

Prior Authorization, Revenue Cycle Management, RCM, Insurance Billing, Claim Denials, Medical Necessity, Retro Authorization, Gold Carding, Private Practice, Practice Management,  The Claim Game

TAKEAWAYS

Anticipatory 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.

CHAPTERS

00:00 Introduction: Entering the Prior Authorization Gate

04:03 The Three Hurdles of Prior Authorization

11:15 Access vs. Cost: The Prior Authorization Battle

16:01 The Myth of Retro Authorization

18:11 The Tools You Need to Master Prior Authorization

20:46 Case Study: The Importance of Tracking Authorizations

22:53 Conclusion: Winning the Prior Authorization Game

RESOURCES

Today Sponsors: Blueprint

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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

Is 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 Game

KEYWORDS

​​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, Documentation

TAKEAWAYS

​​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.

CHAPTERS

00:00 Introduction: Your Two-Step Strategy to Cut Denials

02:55 Creating Your Payer Playbook: Contacts, Codes & Clear Ownership

07:36 The Payoff: How E&B Checks Keep Your Claims Alive

09:01 The E&B Checklist: Verifying Coverage Before the First Session

12:02 The E&B Defense Strategy: What Happens When You Don’t Get It Right

15:37 Case Study: When Missing Steps Cost Thousands

18:09 Conclusion: The Foundations for a Strong, Repeatable E&B Process

RESOURCES

Today Sponsors: Blueprint

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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

Host 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.

KEYWORDS

Insurance 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)

TAKEAWAYS

E&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.

CHAPTERS

00:00 Introduction: Kelley’s Journey to Practice Solutions

04:19 Who Should Check Benefits—Practice or Patient?

06:59 Eligibility Checks Aren’t a Guarantee

08:54 The Most Common Eligibility Mistake

12:47 EHR vs. Payer Portals: Where to Trust Your Data

15:17 How to Talk Insurance With Patients

18:10 Eligibility Overhaul: Templates, SOPs & Intake

20:52 Open Enrollment Chaos: Preparing for January

22:19 Coordination of Benefits 101

25:09 Multi-Site Credentialing & Eligibility

26:13 How Payer Volume Impacts Eligibility Work

28:28 The One Detail You Can’t Miss: Authorization

30:30 Eligibility Mastery: Templates, Portals, Patterns

31:58 Conclusion: Foundations for Sustainable Expansion

RESOURCES

Today Sponsors: Blueprint

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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.

In 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.

KEYWORDS

Revenue Cycle Management, RCM, Insurance Billing, Private Practice, Practice Management, Eligibility and Benefits, Prior Authorization,  Claim Denials, Patient Care, Cash Flow

TAKEAWAYS

E&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.

CHAPTERS

00:00 Introduction to Revenue Cycle Management

01:59 Understanding Eligibility and Benefits Verification

05:15 The Workflow of Eligibility and Benefits

09:58 Prior Authorization: A Critical Step

11:24 Communicating with Patients Effectively

13:45 Tools for Managing Eligibility and Benefits

16:02 Case Study: The Importance of Verification

18:28 Conclusion: Turning Process into Practice

RESOURCES

Today Sponsors: Blueprint

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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

You’ve mastered the day-to-day tasks of patient registration, but how do you know if your processes are actually winning? In this episode, Jeremy and Kathryn Zug zoom in on the Key Performance Indicators (KPIs) space within the Patient Registration territory of The RCM Game Board. They break down how practice owners can stop being reactive and start being proactive by moving beyond the day-to-day desk tasks and tracking essential data.

This deep dive into measuring your practice's success reveals the vital metrics that transform patient frustrations into a smooth, positive first impression and ensure your practice's financial health is aligned with your goals. Learn why the patient intake process, if not optimized, can create costly bottlenecks, delay cash flow, and put your practice at risk. It's time to put your data to work and turn those claim denials into deposits.

In this episode, we cover the critical KPIs for Patient Registration:

Provider Utilization: This goal-setting metric measures the percentage of a provider's desired available time filled with appointments and tells you how effectively your scheduling and flow processes are working. A low rate is a huge red flag for untapped revenue.

Missed or Canceled Appointments: Learn how to measure this rate and what a high number indicates about poor patient communication, unclear expectations, or an inconvenient scheduling process.

Form Handling Audit Pass Rate: This crucial HIPAA compliance metric directly impacts your revenue cycle! Learn why intake errors are a leading cause of rejections and denials and how to track the accuracy of your patient data and forms.

Patient Satisfaction Survey Analysis: Turn subjective patient feedback into actionable data to identify friction points that cause patients to drop out of care and ensure your first impression is a powerful one.

KEYWORDS

Revenue Cycle Management, RCM, Patient Registration, KPIs, Provider Utilization, Practice Management, Medical Billing, Insurance Billing, Healthcare Business, Form Handling Audit, HIPAA Compliance, Practice Growth

TAKEAWAYS

Move Beyond the Day-to-Day: Get a clear picture of your practice's health by conducting a monthly data pull on key metrics to identify bottlenecks, improve patient retention, and increase revenue.

Utilization is Goal-Driven: Provider Utilization is a goal-setting activity that measures your scheduling's effectiveness against the provider's desired hours, not just their physical availability. Low utilization can be a sign of a bad patient intake process, a provider with overly specific preferences, or ineffective scheduling.

Cancellations Are a Red Flag: A high rate of missed or canceled appointments is a big red flag that you must look at weekly. To correct this, run a test of your patient registration process (a "ghost shopper" test) and implement a solid wait list.

HIPAA & Claim Accuracy Are Linked: The Form Handling Audit Pass Rate is vital because intake errors and incomplete forms are a leading cause of rejections and denials—which delays cash flow and puts your practice at risk of HIPAA violations.

Ask Actionable Questions: When designing patient satisfaction surveys, the more granular the questions, the better. Ask questions directly linked to changes you are willing to make to find patterns and focus your improvements.

KPIs Create a Predictive System: A comprehensive KPI dashboard aggregates your metrics for a bird's eye view, helping you move from a chaotic, reactive process into a predictable, proactive system that ensures your practice is running the thing, not the other way around.

CHAPTERS

00:00 Introduction: Mastering the Patient Registration Metrics

02:09 From Tasks to Insights: Evaluating Patient Registration

04:28 Provider Utilization and Practice Health

06:42 Pulling and Analyzing Utilization Metrics

08:43 When Utilization Drops: Finding the Root Cause

14:09 Tracking Missed and Canceled Appointments

20:08 Form Handling Audit: Protecting Compliance and Cash Flow

25:05 Turning Feedback into Action: Patient Satisfaction Surveys

30:03 Dashboard Overview: Turning Metrics into Insight

32:09 Case Study: Using KPIs to Improve Patient Registration

33:59 Conclusion: Moving Forward with Data-Driven Decisions

RESOURCES

Today Sponsors: Blueprint

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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: Patient Registration KPI Dashboard

This week on The Claim Game, Jeremy and Kathryn Zug make the final move in the Patient Registration territory of the RCM Game Board: 

Checkout. It’s easy to think the work is done when a session is over, but this final step is absolutely critical for a practice’s revenue cycle and reputation.

We break down the key elements of a solid checkout process—from physically guiding the patient to the checkout person and ensuring payment authorization works, to the essential practice of scheduling the next appointment on the spot. We discuss the tactical process for handling outstanding patient balances, including setting up payment plans for past due debt before the patient leaves the desk. Most importantly, we cover how to talk about money without damaging your relationship with the client, proving that clear, well-trained communication is the ultimate tool for diffusing emotion.

Plus, hear a fascinating case study about a practice that revolutionized its efficiency by measuring a single, unexpected KPI at checkout.

KEYWORDS

Private Practice, Revenue Cycle Management, Medical Billing, Insurance Billing, Mental Health Billing, Patient Checkout, Cash Flow, Patient Collections, Practice Growth, RCM Best Practices

TAKEAWAYS

Checkout Closes the Loop: A patient’s registration isn't complete until the first checkout has successfully happened, and this process is a major reputation-building activity.

The Three Key Actions at Checkout: A solid checkout process focuses on three tactical elements: 1) Collecting payment (and verifying the payment authorization works); 2) Scheduling the next appointment ; and 3) Offering to answer any questions.

Resolve Past Due Balances Now: Do not allow patients to leave the desk if they have past due balances without setting up a clear payment plan. Practice Solutions’ policy is to collect the current balance in full and set up a plan for the historical debt; you don't want to add to the debt.

Communication is the Key to Customer Service: Make sure your checkout person is extremely well-trained and good with people. Information is so good at diffusing emotion. They need to be able to clearly read an ERA or claims notes to explain why a balance exists in layman's terms—turning a potential confrontation into a transparent discussion.

Pitfalls to Avoid: The biggest pitfalls are failing to collect payment at the time of service, which leads to patient aging, and surprising patients with unexpected bills months or years later. Your patient aging shouldn't exist.

Essential Tools: Two key tools are the Payment Authorization Form (a legally binding document giving permission to charge a card) and the Checkout Checklist (a procedural guide for staff). These ensure consistent and correct application of your financial policies and empower your staff to have clear conversations about money.

CHAPTERS

00:00 Introduction: Completing the Registration Journey

03:48 Turning Checkouts into Cash Flow

08:14 Money Conversations that Build Trust

13:05 Avoiding Checkout Pitfalls

16:30 Power Tools for the Front Desk

20:26 Case Study: When Checkout Data Changes Everything

24:46 Conclusion: Checkouts that Build Reputation

26:21 Resources and Educational Opportunities

RESOURCES

Today Sponsors: Blueprint

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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: Checkout Checklist, Payment Authorization Form

Welcome back to The Claim Game! In this round of mastering Revenue Cycle Management, we're taking a magnifying glass to the crucial territory of Patient Registration and zooming in on the seemingly "riveting" world of HIPAA Compliance. We know that when practice owners hear "HIPAA," their first instinct might be to "run for the hills", but understanding this federal law is absolutely vital for your practice's bottom line and your peace of mind.

Kathryn and Jeremy break down the three core rules—Privacy, Security, and Breach Notification —and why patient registration is ground zero for proper handling of Protected Health Information (PHI). We also dive into a candid discussion about the risks of offshoring patient data, noting that HIPAA is an American law and the lack of data safety guarantees and potential legal complications overseas should be a huge consideration when choosing a vendor.

This episode is packed with specific, actionable protocols, including the non-negotiable need for staff training, the importance of two-factor authentication (especially after the Change Healthcare breach) , secure digital storage (no downloads to your desktop!), and the process for handling everything from physical records to a breach notification. We end the episode with a real-world case study card that shows the costly pitfalls of discussing PHI in public spaces, like a waiting room.

It's time to turn those claim denials into deposits and ensure your practice is not only compliant but confident.

KEYWORDS

HIPAACompliance, RCM, Patient Registration, PHI, Protected Health Information, EHR, Security Rule, Privacy Rule, Breach Notification, Practice Solutions, The Claim Game

TAKEAWAYS

​​HIPAA is Your Law, Not a Suggestion: HIPAA stands for the Health Insurance Portability and Accountability Act and is a federal law establishing standards to protect sensitive Patient Health Information (PHI).

Registration is Ground Zero: Patient registration is the first step where you collect, store, and transmit PHI (Name, DOB, Insurance ID, even IP addresses), making this a critical area for compliance.

Offshoring PHI is a Risk: Companies outside the US are not held to the same HIPAA standards, creating a data safety risk for your practice and your patients. We choose to keep all of our staff stateside for this reason. If you are working with vendors, always ask for a Business Associates Agreement (BAA).

The 3 Rules: Privacy, Security, & Breach Notification: You must be mindful of how you govern PHI (Privacy Rule) , how you protect electronic PHI (Security Rule) , and your protocol for notifying affected individuals/HHS if a breach occurs (Breach Notification Rule).

The Compliance Officer is NOT the Intern: Assign a stable, organized compliance officer to maintain documentation, monitor legislation, train staff, and handle breach notifications.

Security Must Be Multi-Layered:

Digital: Utilize HIPAA-compliant systems (like a secure EHR), encrypted emails/portals, and two-factor authentication for all software access.

Physical: Limit physical access (locks, key cards) , position screens to prevent unauthorized viewing (privacy screens!) , and securely dispose of paper PHI (shredding or burning, not s'mores).

Oops is Not an Option: Red flags include leaving documents visible, storing digital PHI on personal, unencrypted devices, discussing patient information in public spaces (like the waiting room), or improperly disposing of paper records.

CHAPTERS

00:00 Introduction: Navigating HIPAA in Patient Registration

03:53 The Hidden Risks of Offshoring Patient Data

07:54 Privacy, Security, and PHI: The Rules Every Practice Must Follow

18:09 Building HIPAA Protocols That Actually Work

22:03 HIPAA Security Rule: Systems, Safeguards, and Access Control

24:36 Common HIPAA Mistakes (and How to Avoid Them)

25:17 When a Breach Happens: What to Do Next

27:21 Your HIPAA Toolkit: Templates, Logs, and Lifesavers

29:24 Case Study: A Real HIPAA Violation in the Waiting Room

32:12 Conclusion: Putting HIPAA Compliance Into Practice

RESOURCES

Today Sponsors: Blueprint

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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: HIPAA Compliance Guide

Are you tired of grappling with insurance denials due to a simple mismatch in credentialing? Patient registration is more than just a clerical task—it's a key part of your RCM strategy, and this episode zooms in on the next critical step: 

Provider Assignment and Scheduling. Matching the patient to a provider with the right credentials and specialty is crucial for ensuring a smooth eligibility match, preventing costly blunders, and guaranteeing you get paid. This process, which ideally begins on the intake call, requires collecting both patient information (insurance, presenting problem, preferences like language and availability) and using your provider’s preferences and utilization limits to find the best possible fit. Once assigned, getting the patient on the calendar requires granular availability checks and clear 

Appointment Scheduling Guidelines that detail protocols for new patients, handling reschedules, tracking session limits, and managing insurance changes. Finally, managing your wait list is essential; treat it as a powerful tool for converting hot leads, filling cancellation slots, and ensuring optimal provider utilization to protect your revenue and reputation.

KEYWORDS

Scheduling, Intake Process, Eligibility Match, Credentialed Provider, Insurance Denials, EOBs, Provider Utilization, No Shows, Cancellations, Wait List, Patient Preferences, Provider Availability, Appointment Scheduling Guidelines, Out of Network, Medicaid Carve Out

TAKEAWAYS

Assignment is Strategy, Not Clerical: Integrate provider assignment into your RCM strategy, recognizing that matching the patient's needs and insurance to the provider’s credentials and specialty is crucial for getting paid.

Gather Both Sets of Preferences: Don't just collect patient availability and presenting problems. You must also know the provider’s preferences for utilization (caseload capacity), language, and patient type to ensure a good fit and prevent provider burnout.

Address Carve-Outs Early: Be vigilant for specific carve-outs or plans that may not match your provider’s credentialing, even if they appear "in-network" with the general payer. A mismatch can result in a significant loss of revenue.

Document Your Procedures: Create a comprehensive set of Appointment Scheduling Guidelines that includes protocols for booking, tracking session limits/authorizations, handling patient rescheduling, and managing insurance changes or benefit stage changes.

Treat Your Wait List as Revenue: Organize your wait list by key patient and provider match criteria and check it regularly to move patients into open cancellation slots or newly available appointments. Use it to manage provider under-utilization.

CHAPTERS

00:00 Introduction: Setting the Stage for Patient Registration

01:52 From Intake to Calendar: Matching Patients with Providers

04:00 Strategy Behind Provider Assignment

07:24 Managing Provider Utilization

10:30 From Reschedules to No-Shows: Building Strong Scheduling Policies

12:53 The Power of a Well-Managed Waitlist

17:06 The Four Essential Tools for Provider Assignment & Scheduling

21:30 Case Study: From Revenue Loss to Patient Dissatisfaction

24:51 Conclusion

RESOURCES

Today Sponsors: Blueprint

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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:  Appointment Scheduling Guidelines, Waitlist, Provider Assignment Tool, Provider Availability and Preference Form

In this episode of The Claim Game, Jeremy sits down with Joe Murphy, the CEO and Co-founder of Checkpoint EHR. Joe shares his unique journey from the high-paced world of telecommunications to the mission-driven sphere of behavioral health technology, focusing on Checkpoint's core value: "Simply, period".

Joe discusses how Checkpoint is working to move EHR systems into the background by eliminating "the tool that everybody hates" and making the process so subtle and simple that providers don't have to think about it. The conversation dives deep into the strategic use of technology to solve the biggest friction points for practices, including "hands-free billing" , the importance of intuitive design, and how customization reduces noise and error opportunities.

Crucially, Joe provides a forward-looking perspective on the rapid pace of change in the healthcare technology landscape. He explains how Checkpoint is becoming an "AI first focused company" , the incredible productivity gains AI offers (including tenfold increases for developers) , and the critical need to treat AI as a thought partner, not a thought leader, to avoid the risk of "hallucination". Finally, Joe details Checkpoint's unwavering commitment to HIPAA compliance, why US-based data centers are non-negotiable, and his advice to practice owners: don't be afraid to "fail forward".

KEYWORDS

Private Practice, Revenue Cycle Management, EHR,  Electronic Health Records, AI in Healthcare, Medical Billing, Behavioral Health, Checkpoint EHR, Hands Free Billing, Credentialing, HIPAA

TAKEAWAYS

The Mission Moment: Joe's shift from the revenue-focused world of telecom to healthcare was driven by the desire to "make a difference in everybody's community" by helping clinicians address the mental health crisis. Checkpoint EHR's core mission is to "help those who help others".

The EHR that Fades into the Background: Checkpoint's goal is to be so subtle and simple that a provider doesn't have to think about it. They work to reduce the number of choices a user makes to narrow down opportunities for mistakes, which helps reduce claim denials.

Hands-Free Billing is Key to Cash Flow: Checkpoint emphasizes "hands-free billing" where first-time submissions are automatic and quickly go out the door. This frees up billing staff to spend time on more critical issues like denials or rejections, which is where money is truly on the table.

Usage-Based Pricing Reduces Burden: Checkpoint's model compensates the company only when the practice gets paid. This means costs flex with a practice's revenue (e.g., lower cost during seasonal slowdowns) and eliminates extra charges for claim resubmissions.

AI as a "Serious Player": Joe sees AI as the next major leap forward in technology, similar to the internet's impact. Checkpoint is an "AI first focused company" and has seen productivity increase tenfold on its development team since integrating AI tools.

AI Must Be a Thought Partner: When using AI, providers must stay in control and treat it as a thought partner, not a thought leader. This is critical to combat "hallucination," a phenomenon where AI is designed to always give a convincing response, even if it has to make up the answer.

Data Security is Non-Negotiable: Checkpoint ensures patient data protection by requiring all platforms to be HIPAA compliant, maintaining high access controls, using US-based HIPAA-compliant data centers, and avoiding offshoring data.

The Importance of Clinician-Trained AI: Checkpoint's AI-assisted notes are trained by licensed professionals, ensuring responses are reliable and clinically sound, rather than being trained by user data or making responses based on the "popularity of what other users are doing".

Advice to Practice Owners: Fail Forward: Joe's advice is to partner with your EHR vendor, treat them as a partner and not an adversary. Most importantly: "If you're not failing, you're not trying hard enough". Don't be afraid to "fail forward" by learning from mistakes and empowering your team to own their decisions.

CHAPTERS

00:00 Introduction: Joe’s Journey into Health Tech

05:45 A Lifetime of Innovation: Lessons Across Tech Revolutions

07:10 Signal Over Noise: A Different Approach to EHRs

09:52 Automation That Pays: How Checkpoint EHR Boosts Cash Flow

14:26 Eliminating Hidden Fees: A Different EHR Pricing Model

16:42 Simplifying the Patient Experience in EHRs

18:59 How AI is Reshaping Patient and Provider Experiences

27:15 Protecting Patient Data While Innovating with AI

31:00 The Importance of U.S.-Based Data Centers

32:44 Simple Strategies to Learn AI

34:27 A Roadmap for New Tech in Practices

36:44 Checkpoint's Role in Patient Care Ecosystem

38:38 Navigating Policy Shifts: Staying Resilient Amid Change

42:53 Conclusion: Advice for Practice Owners

RESOURCES

Today Sponsors: Blueprint

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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.

Welcome back to The Claim Game, the podcast that helps you turn claim denials into deposits! In this episode, we're diving into the second territory on our RCM board: patient registration. Jeremy and Kathryn Zug zoom in on the very first stage of this process—intake—and explain why perfecting it is so critical for both your practice's reputation and bottom line.

Kathryn explains that intake is about more than just paperwork; it’s about collecting accurate data to prevent future rejections. A poor process can cause a patient to abandon care before it even begins, while a smooth one sets the tone for the entire patient experience. We dive into the specific information you need to collect during the initial intake call, from demographic and insurance details to the patient's "pickle" or presenting problem. We also cover essential follow-up steps, such as sending appointment confirmations, intake forms, and visit instructions that put your patients at ease.

The conversation also highlights the importance of creating a formal, clear process for intake. Just like a McDonald’s burger is made the exact same way every time, a standardized intake process ensures consistency regardless of who is doing it or when. We discuss key resources a practice needs, including an internal administrative intake packet with a scripted logic tree and an external patient intake form. A good EHR can serve as a central hub for all this information, helping to streamline the process, though not all of them are created equal.

Finally, we hear a case study about a practice that assigned a client to a clinician who didn't take their insurance. This is a reminder that simple mistakes in the intake process can be easily prevented with a clear, well-documented system, protecting both your revenue and your patient relationships. It is a big deal to get intake done well because you have to get it right the first time.

KEYWORDS

Intake, Patient Registration, Revenue Cycle Management, RCM, Insurance Billing, Private Practice, Practice Management, Claim Denials, Patient Experience, EHR, Administrative Intake Packet, Patient Intake Form, Practice Health, Credentialing, Patient Portal

TAKEAWAYS

Intake is Your First Impression: A smooth intake process is crucial for setting expectations and preventing patient frustration from the start. A bad process can cause patients to abandon care.

Standardization is Key: Create a clear, formal, and repeatable intake process for your practice. This ensures consistency and prevents mistakes, regardless of who is handling the intake call.

Prevent Rejections at the Source: Intake errors are a leading cause of claim rejections. By collecting accurate demographic and insurance information up front, you can save significant time and headaches down the road.

Clarity is Kindness: Define the flow of communication between your front office and billing department. When the rules are not clearly defined, it causes frustration for everyone, including the patient.

Utilize Intake Resources: Essential tools for a successful intake process include an internal administrative intake packet with a scripted logic tree and a patient intake form for the client.

CHAPTERS

00:00 First Impressions: Perfecting the Intake Process

07:20 Confirm, Remind, Prepare: The Post-Intake Essentials

10:39 From Front Desk to Billing: Defining the Flow

14:59 Consistency Is Key: Why Intake Must Be the Same Every Time

17:08 The Administrative Intake Packet: Your Secret Weapon

23:49 The Patient Packet: Intake from Their Side

25:49 From SOPs to Portals: Building a Repeatable Intake Process

27:22 How Your EHR Can Make or Break Intake

30:24 Case Study: Consequences of Poor Intake Practices

30:45 The Importance of Effective Intake Processes

32:09 Conclusion: Mastering the First Step – Intake Foundations and Tools

RESOURCES

Today Sponsors: Blueprint

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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: We mentioned several images in today's Episode

Administrative Intake Packet

Patient Intake Packet

In this episode of The Claim Game, Jeremy Zug interviews Maya Topitzer, the founder of Breksey, an AI-powered client relationship management (CRM) tool built to help clinicians run their private practices like thriving businesses. The discussion dives into a critical, often-overlooked pain point for practice owners: patient registration.

Maya explains that patient registration is more than just booking an appointment; it's a broad process that starts with a potential client's first inquiry and ends with their initial visit. The biggest pain points she sees are the endless back-and-forth communication, which can lead to missed opportunities, and the burden on practice owners' personal time. Jeremy and Maya share how AI and technology, when used ethically, can "crack the code" on these challenges.

The conversation covers the hidden costs of outdated registration systems, such as lost revenue from slow response times and the burnout that comes from administrative work encroaching on nights and weekends. Maya explains how Breksey's technology helps by converting more inquiries into booked appointments and streamlining the process to reduce data entry errors that cause billing headaches down the line. They also touch on the importance of patient experience and how AI can provide a more personalized, less "clunky" intake process.

The episode concludes with a look at the future of AI in practice management and Maya's core piece of advice for all healthcare professionals: ask for more money and remember your power.

KEYWORDS

Revenue Cycle Management, RCM, Patient Registration, AI for Healthcare, Practice Management, Mental Health Billing, Credentialing, Claim Denials, EHR, Payer, Private Practice, Breksey

TAKEAWAYS

Patient Registration is Your Top Funnel. Patient registration isn't just about scheduling; it's a critical part of the revenue cycle that starts from the very first inquiry. Optimizing this process can significantly impact your practice's growth and financial health by ensuring you don't miss out on potential clients.

AI Can Maximize Your Time and Revenue. AI-powered tools can help you reclaim personal time and capture lost revenue by automating the back-and-forth communication and streamlining intake. According to Maya, practices using Breksey can double their conversion rate from inquiry to booked appointment.

"Bad Data In" Equals "Big Headaches Downstream." Errors in patient registration, like data typos or missing information, create a "massive headache" for billers later on and can lead to claim denials. Technology helps reduce this margin for error by capturing accurate data right from the start.

The Future of Tech is Simple and Conversational. Jeremy and Maya agree that the goal for future practice management technology is to move away from cumbersome, repetitive clicks and toward a more conversational interface. This would allow clinicians to focus on patient care, not paperwork.

You Have More Power Than You Think. Maya's final piece of advice is a powerful one: remember your worth and don't be afraid to ask for more money. As a professional, you have the power to negotiate and ensure your services are not undervalued.

CHAPTERS

00:00 Introduction to Breksey and Its Mission

05:26 Reclaiming Time and Revenue in Patient Intake

09:22 AI Myths in Patient Registration

12:35 Doubling Conversion Rates with Breksey

17:21 Reducing Errors, Reducing Friction: A Better Patient Journey

20:08 Addressing Data Privacy Concerns in AI

22:36 Clinicians as Partners, Not Products

24:55 Revenue Cycle Wins Through Better Registration

27:36 From Community Insights to Insurance Leverage

29:54 Choosing the Right AI for Patient Registration

31:50 Regulation, Risk, and Responsible AI

34:34 Reducing Admin, Maximizing Care: The Future of Practice Tech

37:10 Conclusion: Maximizing Your Practice’s Potential

RESOURCES

Today Sponsors: Blueprint

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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.

Breksey: A comprehensive solution designed to empower therapists in private practice.

In this episode, we're taking a strategic pause to get a behind-the-scenes look at the very game we’re playing by talking to a game changer himself, Uriah Guilford. He's a licensed therapist, group practice owner, and the head nerd at Productive Therapist, a virtual assistant company that serves providers in private practice.

We're diving into the complexities of the patient registration process and uncovering the real costs of inefficiency, including lost revenue, patient dissatisfaction, and staff burnout. Uriah shares a powerful story from his early days that underscores why patient registration and timely callbacks should be a top priority for every practice. We'll also discuss how early adoption of technology and AI, like conversational AI agents, can transform your intake process and provide a level of service that will "surprise and delight" your clients.

Finally, we’ll talk about how to get started on overhauling your intake process and the value of outsourcing your intake to a virtual assistant. You'll learn the single most important thing to do when you're ready to improve your process and discover the one piece of advice Uriah would leave you with if he could only share one thing about patient intake.

KEYWORDS

Revenue Cycle Management (RCM) , The Claim Game , Patient Registration , Patient Intake , AI, Virtual Assistant , Productive Therapist , HIPAA , Private Practice

TAKEAWAYS

The Phone and Calendar are Key: If you want to dominate your market, you have to manage two things: the phone and the calendar. A fast, efficient response to new inquiries is the highest level of service you can offer.

A Bad Intake is Costly: Inefficiencies in the patient intake process can lead to negative client experiences, lost revenue, and practice owner or staff burnout. A solid intake process is the "opening act" to a client's experience with your practice.

Delegate to Grow: Many therapists struggle to delegate and wait too long to get help. Hiring a virtual assistant to handle the intake process can be a game-changer, allowing you to maximize your impact and grow your practice at a much faster rate.

Leverage AI for Intake: AI tools and conversational AI agents can significantly improve the intake process by answering questions and even booking appointments, even when staff are unavailable. This allows practice owners to do more in less time.

Secret Shop Your Own Process: The single best place to start when overhauling your patient intake is to "secret shop" your own process. By going through every step from the client's perspective—from the voicemail message to the client portal login—you will find areas to improve.

Aim for Surprise and Delight: The ultimate goal for your intake process should be to make it "shockingly amazing" and "surprisingly wonderful" for your clients.

CHAPTERS

00:00 Introducing Uriah Guilford: Nerd, Therapist, Innovator

06:38 How Intake Systems Make or Break a Practice

11:18 Virtual Assistants: The Secret to Scaling Your Practice

16:07 AI, Insurance, and the Future of Intake Systems

23:00 VA or In-House? Finding the Best Fit for Your Practice

24:52 From Structure to Flexibility: Managing Clinician Preferences

28:19 From Chaos to Clarity: Fixing a Broken Intake System

30:21 Claude, ChatGPT, and Intake Hacks

34:54 Accessibility, AI, and the Future of Therapy

37:35 Where to Get Help: ProductiveTherapist.com

38:37 Conclusion: One Guiding Principle

RESOURCES

Today Sponsors: Blueprint

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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.

Welcome back to The Claim Game! In this episode, Jeremy and Kathryn Zug shift from the "Credentialing" territory of the RCM game board to a new, crucial area: Patient Registration. They explain that while credentialing is about getting your player piece on the board, patient registration is about getting other players—your patients—onto the board so you can actually start playing.

This episode offers a comprehensive overview of the patient registration territory, breaking it down into five key subcategories:

Intake: The process of collecting information. The hosts emphasize that this isn't just "stuffy paperwork" but a critical, dynamic process that sets the stage for a smooth revenue cycle and a great first impression. They share that a poor intake process is directly tied to a high volume of claim rejections and denials.

Provider Assignment & Scheduling: Matching patients to the right provider. This includes considering patient preferences like gender, language needs, and presenting problems to ensure a good match and prevent patient churn.

Checkout: The process isn't complete until the first checkout is done. The hosts explain why this is a critical moment for a practice's reputation and financial health, as it's the best opportunity to collect payments and schedule the next appointment.

HIPAA Compliance: Jeremy outlines the three main HIPAA rules—Privacy, Security, and Breach Notification—and warns that providers should always do more than the bare minimum to hedge against non-compliance, likening it to building a fence 10 feet away from the legal requirement.

Key Performance Indicators (KPIs): The hosts emphasize the importance of tracking KPIs for every territory, including patient registration. They suggest that metrics like provider utilization and patient retention can serve as an early warning system for problems in the patient registration process.

Finally, Jeremy shares a personal story about a triple-booking blunder from his early days, highlighting the importance of having a clear process and humility in place.

KEYWORDS

RCM, Revenue Cycle Management, Credentialing, Patient Registration, Intake, Provider Assignment, Scheduling, Checkout, HIPAA Compliance, KPIs, Claim Denials, Claim Rejections, First Impression, Patient Retention, Patient Care, Revenue

TAKEAWAYS

Patient Registration is Your First Impression: Patient registration is the forward-facing step that sets your practice's reputation. A smooth, clear process directly impacts patient retention and can prevent billing nightmares down the road.

A Clogged Pipeline Leads to Loss: Just like you don't want to wait in credentialing, you don't want to get hung up in patient registration. A well-defined, efficient process helps get patients into the practice and seeing providers as quickly as possible.

Details are a Lifesaver: Collecting correct and complete information at intake—including IDs and insurance cards—is not "stuffy" but a "lifesaver" that prevents a high volume of claim rejections and denials later on.

The First Checkout is a Must: Patient registration isn't complete until after the first checkout. This is your best chance to collect payment and schedule the next appointment, which is "way easier" than trying to do it over the phone later.

Hedge Against HIPAA Breaches: The penalties for HIPAA non-compliance are steep. Instead of doing the bare minimum, build in systems and procedures that keep you "10 feet away" from a potential breach.

CHAPTERS

00:00 Introduction to Credentialing and Its Importance

02:31 Understanding Credentialing KPIs

04:33 Insurance Revenue Target Analysis: Tracking KPIs to Optimize Your Payer Mix

10:59 Time to Contract: Measuring Lead Times for Smarter Credentialing

16:36 Application Completion Accuracy: Pinpointing Errors, Patterns, and Process Gaps

22:11 Credentialing Efficacy: Measuring Success Rates by Payer

25:42 Application Denial Reasons: Uncovering Why Submissions Fail

29:49 Getting Started with Your Credentialing KPI Dashboard

34:12 Case Study: How Credentialing KPIs Turned an Underperformer Into a Key Asset

37:51 Conclusion: Turning Data Into Practice Growth

RESOURCES

Today Sponsors: Blueprint

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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.

In this final installment of the credentialing series, Jeremy and Kathryn Zug break down how practice owners can track and measure the success of their credentialing efforts using a KPI dashboard. They explore five essential KPIs—insurance revenue target analysis, time to contract, application completion accuracy, credentialing efficacy, and application denial reasons—and explain how each metric empowers you to make smarter business decisions. From identifying underperforming payers to training (not firing) staff, this episode shows how turning subjective frustration into objective data can transform your practice’s revenue cycle.

KEYWORDS

Credentialing KPIs, Revenue Cycle Management, Healthcare Practice Management, Insurance Denials, Credentialing Dashboard, Payer Relationships, Application Accuracy, Practice Solutions, Hourglass Learning Hub

TAKEAWAYS

Why KPIs Matter: Tracking metrics turns credentialing from a one-off task into an ongoing, data-driven process that strengthens both staff performance and payer partnerships.

The Five Credentialing KPIs:

Insurance Revenue Target Analysis – Ensure your payer mix supports profitability goals.

Time to Contract – Measure how long it takes to go in-network and optimize hiring timelines.

Application Completion Accuracy – Identify training needs or process gaps that slow down credentialing.

Credentialing Efficacy – Assess the percentage of successful applications by payer.

Application Denial Reasons – Drill down into whether denials are due to closed panels, errors, or qualifications.

Data = Better Decisions: KPIs help determine whether to retrain staff, refine payer lists, or renegotiate partnerships.

Case Study: A group practice avoided firing an employee by using KPI data to identify a training need—transforming her into a high-performing credentialer.

Practical Start: Don’t overcomplicate it—leverage the data you’re already collecting in your credentialing logs and EHR reports.

CHAPTERS

00:00 Introduction to Credentialing and Its Importance

02:31 Understanding Credentialing KPIs

04:33 Insurance Revenue Target Analysis: Tracking KPIs to Optimize Your Payer Mix

10:59 Time to Contract: Measuring Lead Times for Smarter Credentialing

16:36 Application Completion Accuracy: Pinpointing Errors, Patterns, and Process Gaps

22:11 Credentialing Efficacy: Measuring Success Rates by Payer

25:42 Application Denial Reasons: Uncovering Why Submissions Fail

29:49 Getting Started with Your Credentialing KPI Dashboard

34:12 Case Study: How Credentialing KPIs Turned an Underperformer Into a Key Asset

37:51 Conclusion: Turning Data Into Practice Growth

38:58 Introduction to The Claim Game Podcast

39:27 Engagement and Feedback from Listeners

39:54 Resources and Educational Opportunities

RESOURCES

The 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.

Learn More About The Claim Game: Visit practicesol.com/podcast

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.

In this episode of The Claim Game, Jeremy and Kathryn Zug dive into the final stage of credentialing: Stage Six, "Manage and Review". While many providers believe that credentialing is a one-time process, this stage is crucial for avoiding unexpected denials and even ejection from payer networks. The hosts compare ongoing credentialing management to maintaining a car after you've bought it, emphasizing that you can't just drive it off the lot and never look under the hood again. They discuss the importance of recredentialing or reattestation, which payers often require every two to three years, and the critical need to keep all your information updated. The episode also highlights the role of Practice Solutions' tools, such as the Credentialing Matrix and the Insurance Contact Reference List, in systematically managing this ongoing process and preventing costly pitfalls.

KEYWORDS

Credentialing, Revenue Cycle Management (RCM), Insurance Denials, Recredentialing, Reattestation, CAQH, Credentialing Matrix, Insurance Contact Reference List, Practice Solutions, The Claim Game, Revenue Cycle, Payer Networks, Done-for-you Billing, Practice Health Check, Hourglass Learning Hub

TAKEAWAYS

Credentialing is an ongoing process, not a one-time event. Neglecting the "manage and review" stage can lead to denials and disenrollment from payer networks.

Proactive scheduling is key to avoiding pitfalls. Providers should regularly review their CAQH account every 6 to 12 months and tag someone in their practice to manage the reattestation dates on their credentialing matrix.

Keep all your information updated with payers. Failing to promptly update changes in your address, services, or provider licenses can lead to denied claims and a payment nightmare.

Use the right tools to stay organized. The Credentialing Matrix gives you a bird's-eye view of every provider's credentialing status, including their reattestation dates. The Insurance Contact Reference List acts as a "living cheat sheet," helping you know exactly who to contact for updates.

Don't let your "set it and forget it" mentality jeopardize your practice's financial health. Consistent, meticulous record-keeping is crucial for protecting your hard-earned in-network status.

A powerful case study illustrates the risks of neglect. One provider was completely wiped from the TRICARE system, demonstrating how a lack of organization and ongoing management can lead to major, time-consuming problems.

CHAPTERS

00:00 Introduction to Credentialing Management

11:04 Common Pitfalls in Credentialing

19:20 Case Study: The Dangers of Neglecting Your Credentialing Management

22:47 Conclusion: Mastering the Metrics

RESOURCES

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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.

This week on The Claim Game, we’re taking a deep dive into the nuts and bolts of one of the most stressful parts of private practice: credentialing. Jeremy sits down with Kay Ward, the founder and CEO of Lanyard Health, a health tech platform that's reshaping how providers get credentialed and stay on top of their status with payers.

Kay, who’s been in the credentialing game for 15 years, shares her journey from a typist to a startup founder, all because she saw an opportunity to solve a massive problem for providers. She explains why credentialing feels so disjointed and burdensome and offers some game-changing advice to help you avoid common pitfalls and delays.

KEYWORDS

Private Practice, Credentialing, Revenue Cycle Management (RCM), Insurance Billing, Payer, Practice Growth, Practice Management, Practice Owners

TAKEAWAYS

The Biggest Fear is Time: The number one question providers have about credentialing is, "How long will it take?". While there's no single answer, you should plan for at least 60 to 120 days, and potentially longer for certain plans like Medicare Advantage and Medicaid.

You Can Be Your Own Bottleneck: One of the most common delays in credentialing is having disorganized or inconsistent information across your documents. A simple error, like putting your name on line one of your W-9 instead of your practice's name, can cause payers to immediately push the application back and create another 30-day delay.

The Waiting Game Never Ends: Credentialing isn't a "set it and forget it" process. You must re-attest your information on platforms like CAQH and Availity every 90 days to comply with regulations like the No Surprises Act. Failure to do so can lead to payers limiting your payments.

DIYing Credentialing Costs You: While it's possible to manage credentialing yourself, the time and energy spent chasing applications and dealing with delays often outweighs the financial savings. Your time is valuable and should be spent on patient care or scaling your business, not navigating the bureaucratic abyss.

Data is Your Power Tool: When it comes to negotiating higher rates with payers, you need data to back up your value. A solid relationship with your biller is crucial because they have the numbers and insights to help you understand if a payer is still feasible for your practice.

CHAPTERS

00:00 Introduction and Technical Setup

03:17 Kay Ward's Journey into Credentialing

07:11 What Really Slows Credentialing Down (and How to Fix It)

11:46 From CAQH to PECOS: Setting Your Practice Up for Success

15:17 The Most Overlooked Mistake That Delays Credentialing

18:55 Recredentialing & Attestations: The Ongoing Responsibility

24:15 The True Cost of DIY Credentialing

29:39 AI Meets Credentialing: Eliminating Delays and Duplication

32:28 How Lanyard Tracks Policy Changes in Real Time

35:00 NCQA Explained: Why It Matters for Providers

36:27 Navigating Sudden Reimbursement Changes

41:50 Proving Your Value: The Key to Better Rates

45:07 Actionable Steps to Fix Credentialing Issues Today

48:17 Case Study: Winning Credentialing Through Communication

50:26 Conclusion: Organization is the Key to Getting Paid

RESOURCES

Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance.

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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.

Lanyard Health: Visit lanyardhealth.com

Lanyard Health Free Credentialing Checklist: Provider Enrollment Checklist.pdf

Serif Health: Visit serifhealth.com

This episode of The Claim Game, "Accessing the Board," features an insightful interview with Cathy Gilbert, an expert with over 30 years of experience in the healthcare industry, including leadership roles at major national payers like Magellan and Beacon Health Options. Cathy shares her unique perspective from the payer's side of the table, demystifying the complex and often frustrating world of credentialing, contracting, and fee negotiations for private practice owners. She explains that while the process can seem like a "black hole," there are rules, and understanding them is key.

KEYWORDS

Credentialing, Provider Network Management, Contracting, Revenue Cycle Management, CAQH, Timely Filing, Rate Negotiation, The Claim Game, Practice Solutions, NCQA, URAC

TAKEAWAYS

Payer's Perspective on Credentialing: The credentialing and contracting processes are two pieces that go hand in hand. Payers have a cost associated with credentialing and want to ensure a provider meets their minimum requirements for licensure, education, and liability insurance before investing in a contract. They're also looking for a need and volume that can support both the provider and the plan's time spent on the process.

Keep Your CAQH Up-to-Date (It's a Dual Effort): A provider's CAQH profile is considered the "gold standard" for credentialing data. It's the provider's responsibility to keep it current and accurate, as plans can and will use this data. Failing to respond to plan requests for information could result in being removed from the network.

The "Black Hole" of Credentialing Has a Lifespan: The credentialing process typically takes 90 to 120 days to complete. A provider's application signature will expire after 120 to 180 days if not processed, requiring the provider to resubmit. Providers should track their application status through the plan's portal and only follow up if the timeframe on the website has passed, as calling earlier will likely not speed up the process.

Relationships Got Taught Out of the Payer Role: While people who work at plans genuinely want to help, their teams are small relative to the number of providers they manage. This has led to a shift away from in-person relationship-building to a more virtual, centralized approach.

You Can Get a Direct Payer Contact: Provider relations representatives are assigned to specific territories, and their information is often publicly available on a plan's website or in the provider manual. You can also search for these contacts on LinkedIn.

Rates and Terms May Be Negotiable: Rates may be open to negotiation, especially for in-demand specialties like child psychiatry or in areas where the plan needs to expand access to care. In terms of contract language, timely filing limits are often negotiable. For any negotiation, be aware that it will likely delay the contracting process.

Big Therapy Tech Firms and Their Rates: Tech-enabled firms were able to negotiate higher rates during COVID-19 to provide access to care. However, plans are now pushing back and renegotiating these rates, particularly for providers already in their network. This creates a unique opportunity for independent private practices to negotiate rates by highlighting that they can add "net new" providers to the network.

Payer Quality Standards Impact Your Practice: Plans are measured on quality metrics like the HEDIS measures. One of the most important metrics is getting a patient into care with a community-based provider within seven days of being discharged from a higher level of care. Some plans offer higher rates to providers who can consistently meet these kinds of standards.

The Power of an EOB: The Explanation of Benefits (EOB) is a power tool for providers. By understanding the "Allowed Amount" on an EOB, you can spot discrepancies and determine if you're getting paid correctly, which is a key to taking control of your revenue.

The Value of the Hourglass Learning Hub: The Hourglass Learning Hub is a comprehensive platform designed to simplify your billing machine. It provides educational articles on key RCM domains, DIY billing resources, and an "Ask the Biller" feature for personalized video responses to complex questions.

CHAPTERS

00:00 Introduction to Credentialing and Provider Networks

03:25 Cathy Gilbert's Journey in Healthcare

05:44 Contracting & Credentialing: The Two Sides of the Payer Process

07:36 NCQA, URAC, and the Accreditation Game

09:36 What Payers Look for in Network Providers

13:48 Measuring Quality in Provider Networks

15:23 CAQH, Compliance, and Network Clean-Up

18:35 Navigating Contractual Obligations

22:17 The Credentialing Timeline Explained

26:23 The Relationship Between Providers and Payers

26:26 Breaking Through Credentialing Roadblocks

33:41 The Right Way to Follow Up on Credentialing

38:39 Navigating Provider Relations and Contacts

41:27 Reading the Fine Print: Contract Clauses That Matter

47:07 Negotiating Higher Rates with Health Plans

52:35 Rate Negotiations and the Power of Transparency Data

57:12 Aggregator Rates, Payer Power, and the Future of Therapy Contracts

01:03:58 Conclusion: The One Rule for Credentialing Success

RESOURCES

The 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.

Learn More About The Claim Game: Visit practicesol.com/podcast

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.

This episode of The Claim Game marks a pivotal moment in the credentialing journey: the final initiation where you truly claim your network territory. Jeremy and Kathryn Zug guide you through the crucial stages of reviewing and finalizing a payer contract, helping you navigate the fine print that can make or break your practice's financial health. This is the stage where you transform a pending application into a legitimate partnership and confidently secure your "game piece" on the RCM board.

KEYWORDS

Credentialing, In-Network, Payer Contracts, Fee Schedule, Timely Filing, Revenue Cycle Management (RCM), The Claim Game, Practice Solutions, Billing, Insurance Denials, Payer Audits, Recoupment, Claim Submission, Patient Registration, Eligibility and Benefits, Practice Management

TAKEAWAYS

The Contract is a Non-Negotiable Review: Never gloss over a payer contract. It's a "vital" document that outlines your responsibilities and those of the insurance company.

Look for Key Clauses: Scrutinize clauses on provider responsibilities (like accepting the negotiated rate as payment in full), payer responsibilities (clear payment timelines, transparent appeals processes), audit and recoupment look-back periods, and termination rules.

A Fee Schedule is a Must-Have: You should "absolutely, positively should not sign anything if you haven't seen a fee schedule" and understand the annual updates. It's the equivalent of accepting a job without knowing your salary.

Patience is a Virtue: Signing a contract doesn't mean you can immediately start billing. Your "start date" is the official green light, and submitting claims before it will result in irreversible denials.

Organize Your Information: Utilize tools like a credentialing application follow-up log, an insurance contact reference guide, and a credentialing matrix to track your progress, document contract details, and keep all your "ducks in a very, very neat row" for future success.

CHAPTERS

00:00 Introduction to Today’s RCM Category: Contract Finalization & Start Date Establishment

02:31 Before You Sign: What to Look for in Insurance Contracts

04:24 Understanding Your Responsibilities as an In-Network Provider

08:58 Holding Payers Accountable in Your Contract

10:1 Dispute Resolution & Appeals: Know the Process

11:47 Audit & Recoupment Clauses: Protect Your Revenue

13:05 The Fine Print on Referrals & Authorizations

13:53 Contract Duration, Exit Terms & Silent Consent

15:28 Compensation & Contracted Rates: What to Know

18:12 Submitting Claims: Deadlines, Details, and Best Practices

22:18 NPI, Tax ID & More: Make Sure It Matches

23:12 You're Not In Yet: Understanding Effective Dates

25:56 Credentialing Tools That Keep You Organized

32:19 The Final Move: Credentialed, Contracted, and In Control

33:57 Case Study: The Cost of Jumping the Gun

37:26 Conclusion: Proceed with Caution, Win with Clarity

RESOURCES

Practice Solutions (practicesol.com)

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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:

Credentialing Application Follow-Up Log 

Insurance Contact Reference Guide 

Credentialing Matrix 

In this episode of The Claim Game, Jeremy and Kathryn Zug tackle the often-dreaded "credentialing black hole" – that period of frustrating silence after submitting your insurance applications. They equip you with a game-changing strategy to transform passive waiting into an active, strategic process. This episode zooms in on Stage 3 of the credentialing process: application follow-up. Learn how to set up a "mission log" to track every application, key information to record, and the optimal timing and essential questions for follow-ups to conquer uncertainty and prevent revenue-killing delays. Jeremy and Kathryn pull back the curtain on common updates you'll receive, what to do if an application is denied, and the importance of documenting everything. They share a powerful success story of a Michigan group practice that turned credentialing into a competitive advantage through proactive follow-up and robust systems. The episode emphasizes that escaping the credentialing abyss is entirely possible with a plan, consistent effort, and the right tools.

KEYWORDS

Credentialing, Insurance Billing, Revenue Cycle Management, RCM, Practice Management, Denials, Follow-up, Healthcare Business, Private Practice, Billing Process, Credentialing Follow-up Log, Practice Solutions, The Claim Game, CAQH, Payer Portal, EHR, NPI, EOB, Contract Finalization, Start Date Establishment, Practice Growth

TAKEAWAYS

The Waiting Game is Active: Don't passively wait after submitting credentialing applications. Proactive follow-up is crucial to prevent delays and lost revenue.

Create a "Mission Log": Implement a system to meticulously track every credentialing application, including insurance company, provider name, status, submission date, employee, notes, and crucially, the next follow-up date. Practice Solutions offers a dedicated log in the Hourglass Learning Hub.

Initial Check-in is Key: Call 3-5 business days after submission, even if submitted online, to confirm receipt and processing with a human. Document this confirmation and any reference numbers.

Ask Two Essential Questions: During your initial check-in, always ask: 1) How long do they anticipate processing will take? 2) How and how soon will you be notified if there's an issue or denial? Log these answers to guide your future follow-ups.

Establish a Proactive Cadence: If notification processes are slow, follow up every two weeks after the initial confirmation to consistently monitor status and promptly resolve any issues.

Document Everything (Notes are Your Best Friend): Jot down call reference numbers, specific instructions, denial reasons, and contact information. This information is invaluable for preventing future pitfalls and building your "cheat code".

Don't Give Up on Denials: If an application is denied, update your log and be prepared to resubmit. Crucially, speak to a person to get every detail about why it was denied to learn from the experience and prevent future issues.

Tools Make the Difference: Utilize resources like a credentialing document checklist, an insurance contact reference list (your "ultimate cheat sheet"), and a credentialing matrix to stay organized and efficient.

Consistency and Strategy Lead to Success: Rolling the follow-up dice isn't about luck; it's about strategy, consistency, and having the right tools to empower your practice and ensure revenue makes it into your bank account.

CHAPTERS

00:00 Introduction to Credentialing: Application Follow-up

03:33 Start your Credentialing Application Follow-up Log

05:19 Determine Your Follow-up Cadence

06:44 Confirm Receipt of Your Application + Ask Important Questions

09:36 Recommended Follow-up Cadence

11:06 Milestone Updates to Look Out For During Follow-up

13:22 What if my Application Gets Denied?

15:02 Follow-up Recommendation Once You Receive Approval

17:13 The Tools Needed to Make This Process Smooth

19:58 Case Study Card: Practice with Butter Smooth Credentialing

23:51 Conclusion: Stage 3 of Credentialing

RESOURCES

Learn More About The Claim Game: Visit practicesol.com/podcast

Book: For a comprehensive guide on navigating insurance, grab your copy of Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance.

The 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.

Join Jeremy and Kathryn Zug in this tactical episode of The Claim Game as they dive deep into the initial stages of the credentialing process: information gathering and application completion. This episode is packed with essential tools and strategies, moving beyond a general overview to provide clear, actionable steps for practice owners and administrators. Kathryn outlines precisely what practice and provider information to collect, how to organize it, and when to consolidate these crucial documents. You'll learn the importance of having supporting documentation, understanding CAQH, and meticulously tracking application statuses to avoid costly denials. Jeremy shares a compelling case study about a clinician who faced significant revenue loss due to improper credentialing, underscoring the critical need for preparation and documentation. Get ready to take decisive control of your practice's financial health by mastering these foundational credentialing steps.

KEYWORDS

Credentialing , Revenue Cycle Management , RCM best practices , Insurance billing , Practice management , Healthcare administration , Payer contracts , CAQH , NPI , EIN , CPT codes , Timely filing , Claim denials , Patient care , Practice Solutions , Hourglass Learning Hub

TAKEAWAYS

Information Gathering is Key: Understand when (ideally before employment or within the first week ), how (sit with an admin ), and what information to collect for both your practice and individual providers.

Consolidate Practice Information: Maintain a single document for your practice's legal business name, owner's names, articles of organization, address, start date, Type 2 NPI, EIN, liability insurance, bank information, contact details, office hours, CPT codes, and disabled accessibility information.

Provider Information is Comprehensive: Be prepared to collect full legal names, driver's licenses, Type 1 NPIs, SSNs, professional licenses, educational details, professional references, CPT codes specific to the provider, and criminal/civil history.

CAQH is Vital: CAQH is a central hub for insurance companies to verify provider credentials and can save you time by consolidating information. An admin can sit with the provider to ensure thorough and consistent completion.

Verify Existing Credentialing: Before submitting new applications, always confirm if a provider is already credentialed with any of your practice's payers, as submitting a full application unnecessarily can cause major delays or issues.

Document Everything Meticulously: Use tools like a credentialing application follow-up log to track the status of each application. Create a payer list chart with portal links, application links, and change form files. These documents are crucial for efficiency, long-term KPI tracking, and seamless transitions when staff changes occur.

Read Applications Carefully: Always review applications thoroughly before submission to ensure all boxes are checked and information is accurate to avoid costly denials and "free work".

Understand Your Credentialing Matrix: Know exactly how you're credentialed with specific plans within insurance companies, not just the company name, to prevent unexpected carve-outs that lead to unpaid services.

Preparation and Documentation Prevents Loss: Inadequate preparation and documentation can lead to significant revenue loss, as highlighted by the case study of a clinician losing months of services due to improper credentialing.

CHAPTERS

00:00 Introduction to Credentialing in Revenue Cycle Management

03:47 Stage 1: Information Gathering - What to Collect for a Practice?

08:14 Stage 1: Information Gathering - What Practice Information to Collect? (Continued)

10:08 Stage 1: Information Gathering - When to collect this information?

11:51 Stage 1: Information Gathering - Who Collects this Information?

13:25 Stage 1: Information Gathering - What Provider Information Do I Collect?

21:00 Stage 1: Information Gathering - Summary

22:12 Stage 2: Application Completion

29:00 Case Study Card: 

33:25 Summary of Stages 1 & 2

34:20 Introduction to The Claim Game Podcast

34:48 Engagement and Feedback from Listeners

35:16 Resources and Educational Opportunities

RESOURCES

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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: We mentioned images in today's EpisodePractice Payer List Image

In this special "Game Changers" episode of The Claim Game, Jeremy Zug sits down with Dan King, co-founder and in-house counsel at Fireside Strategic, to get a behind-the-scenes look at the evolving landscape of healthcare. Dan, a former M&A lawyer and executive coach, shares his unique journey and reveals how his "aha moment" led him to prioritize the human side of business in rapid growth.

Discover Fireside Strategics' mission to acquire and grow outpatient private practices while treating providers "like gold," creating a virtuous circle of people and profit. Dan makes a compelling argument for why in-network practices are actually more valuable from an enterprise perspective, delving into the concept of "insurance arbitrage" and the scalability possible with commercial payers. He also offers candid insights on identifying good insurance partners, the impact of low reimbursement rates on burnout, and the non-negotiable importance of reliable communication in any partnership, whether with an insurer or an M&A firm. This episode provides invaluable strategic advantage for any practice owner looking to optimize their game!

KEYWORDS

Payer Selection, Insurance Partners, Mergers and Acquisitions (M&A), Private Practice, Burnout, Organizational Culture, Strategic Growth, Reimbursement Rates, Insurance Arbitrage, Fireside Strategic, Dan King, The Claim Game, Revenue Cycle Management (RCM), Commercial Insurance, Government Payers, Patient Outcomes, Provider Well-being.

TAKEAWAYS

Prioritize People and Systems for Sustainable Growth: Don't delay building robust people and operational systems. Intentional, slower growth upfront leads to culturally and financially sound businesses in the long term.

In-Network Practices are More Valuable for Acquisition: From an enterprise perspective (especially in outpatient healthcare), practices that are in-network with commercial insurance are more scalable and thus more valuable, due to broader patient reach and the potential for "insurance arbitrage" (applying higher rates across multiple practices in a state).

Higher Margins Empower Better Care: Adding higher-margin services (like specialized diagnostics or advanced treatments) allows practices to pay providers more and invest in infrastructure, leading to better patient outcomes and increased referrals.

Choose Insurance Partners Wisely: Look for responsive insurers who treat providers with respect and have broad coverage. Niche services meeting high demand can also lead to better rate negotiations.

Beware of Low Reimbursement Rates: Consistently low reimbursement rates are a "recipe for burnout" for both practice owners and providers, as it necessitates seeing more patients for less income.

Scale Can Influence Negotiation Power: Larger practices or those with unique niche services can gain more leverage in rate negotiations with insurance companies due to their volume and variety.

Partnership is Key in M&A: When considering an acquisition, prioritize alignment with the founder. A partnership model (where the founder retains a minority stake and operational role) often leads to greater success and a potentially larger second exit.

Communication & Reliability are Paramount: Whether with an insurance company or a business partner, consistent, reliable communication is a crucial indicator of effectiveness and the ability to win the "war of attrition" against bureaucracies.

RESOURCES

Today Guest Information: Dan King and his work at Fireside Strategic

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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.

Are you selecting insurance payers based on hearsay, hoping that more volume automatically means more revenue? You're not alone! In this episode of The Claim Game, Jeremy and Kathryn Zug dive deep into the strategic art of payer selection, dispelling the myth that simply paneling with everyone will lead to a thriving practice. They break down how to align your insurance choices with your long-term practice vision, starting with defining your unique "insurance mix" and clarifying your practice goals.

Discover three common and profitable approaches to insurance mix:

* The Lean Plan: Focuses on maximizing revenue by working with the fewest possible high-reimbursing in-network payers, coupled with private pay clients.

* The Focused Plan: Tailors your payer mix to serve specific patient populations (like Medicare or TRICARE recipients) while balancing profitability with your passion for patient care.

* The Hamburger Plan: Combines in-network high-reimbursing payers with intentional out-of-network billing, offering flexibility but requiring careful administrative management.

Jeremy and Kathryn emphasize that fewer payers can often be better, leading to reduced administrative burden, more control, easier scaling, and ultimately, better patient relationships. They also share critical insights on navigating the financial implications of payer issues like Change Healthcare and TRICARE transitions. Plus, don't miss the inspiring case study of Dr. Eleanor Vance, who built a thriving practice by strategically focusing on a single, dominant payer.

KEYWORDS

Payer Selection, Insurance Mix, Credentialing, Revenue Cycle Management (RCM), Reimbursement Rates, Administrative Burden, Cash Flow, Claim Denials, Patient Registration, Eligibility and Benefits (E&B), Payment Posting, Aging Follow-Up, Claim Submission, Practice Goals, Profitability, Superbills, In-network, Out-of-network, Patient Relationships, Practice Growth.

TAKEAWAYS

Strategic Payer Selection is Crucial: Don't base your insurance choices on hearsay or the belief that "more is always better." Instead, strategically align your payer mix with your long-term practice goals.

Lean is Often More Profitable: Working with a small number of high-reimbursing in-network payers, supplemented by private pay, can lead to significantly higher average reimbursement rates and a much lower administrative burden.

Every Dollar Counts: Even a small difference in per-visit reimbursement ($5 per appointment) can translate to tens of thousands of dollars in annual revenue for your practice.

Mind Your Out-of-Network Strategy: Courtesy billing for out-of-network patients can dramatically increase your administrative burden and expenses. Consider collecting 100% upfront from the patient or utilizing superbills with the reimbursement assigned directly to the patient to avoid chasing these claims.

Prepare for Inevitable Delays: Industry-wide issues (like Change Healthcare or TRICARE transitions) can delay payments, but they rarely mean lost revenue. Maintain a healthy emergency fund and a tight financial policy to weather these periods.

Balance Passion with Profitability: The "Focused Plan" allows you to serve specific patient populations aligning with your passion, but it requires careful caseload management to maintain financial health.

Fewer Payers, Greater Control: Limiting your in-network participation provides more control over your private pay rates, simplifies scaling, and allows for deeper understanding of payer policies, leading to more accurate eligibility checks and stronger patient relationships.

Research is Your Ally: Thoroughly research potential payers by consulting colleagues, scouring insurance websites, and utilizing data companies (like Serif, Clarify Health, and Trek Health) to evaluate market dominance and rates.

Internal Reflection Matters: Beyond external data, consider how a payer will impact your practice's time, cost, workload, and team morale. Choose partners that align with your overall well-being and practice vision.

Prioritize Working On Your Business: A strategic approach to payer selection reduces administrative stress, freeing up your mental energy to focus on improving your clinical services and growing your practice.

RESOURCES

Episode 1: Introducing the Board Landscape: Missed the initial setup of The Claim Game board? Catch up on the six RCM domains with Episode 1 of The Claim Game.

Goal Setting Worksheet: Get clarity on your practice vision with our free  Goal Setting Worksheet.

My Ideal Insurance Mix: An in depth worksheet to help you identify your Ideal Insurance Mix.

Insurance Billing Basics: Steps for Therapists to Successfully Take Insurance: Gain clarity and control over your billing with our game-changing book. Get 15% off by clicking the link → Insurance Billing Basics

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The 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.

Connect with Practice Solutions: Learn more about our services and how we can help you with your billing needs by visiting practicesol.com.

Images: We mentioned several images in today's Episode Credentialing X Payers

Welcome back to The Claim Game! In this episode, Jeremy and Kathryn Zug zoom into the first critical "territory" on your Revenue Cycle Management (RCM) game board: Credentialing. This process is your entry point to accepting insurance, and understanding its nuances is key to your practice's success. The Zugs break down the decision between handling credentialing yourself (DIY) or outsourcing to a specialized service, exploring the pros and cons of each approach to help you choose the best path for your practice.

They then guide you through the six stages of the credentialing journey:

Stage 1 - Information Gathering: The foundational phase of meticulously collecting all necessary practice and provider data, often utilizing platforms like CAQH.

Stage 2 - Application Completion & Submission: Filling out forms with painstaking attention to detail, ensuring everything matches your supporting documentation.

Stage 3 - Application Follow-Up: An active and ongoing process of consistently tracking your application's status, confirming receipt, and proactively resolving any flags or denials.

Stage 4 - Contract Finalization: The crucial step of carefully reviewing and understanding your payer contract's terms, responsibilities, and compensation details before signing.

Stage 5 - Start Date Establishment: Understanding that your official in-network status begins on your effective date, not just upon contract signature.

Stage 6 - Manage & Review: Recognizing that credentialing is an ongoing cycle, requiring regular recredentialing/reattestation and updates to your information.

Even if this sounds like a lot, Jeremy and Kathryn assure you that understanding this "bedrock" process empowers you to navigate it successfully and build the practice you envision.

KEYWORDS

Credentialing , RCM , Revenue Cycle Management , Payer Selection , DIY Credentialing , Outsourcing Credentialing , Practice Management , Healthcare Billing , Insurance Billing , CAQH , Information Gathering , Application Submission , Application Follow-up , Contract Finalization , Start Date , Manage and Review , Recredentialing , Reattestation.

TAKEAWAYS

Understand Your Credentialing Options: Decide between handling credentialing in-house (DIY) or outsourcing to a specialized service, weighing control and cost against experience and bandwidth.

DIY Pros & Cons: DIY offers more control and customization, and internal staff can become highly efficient, but it demands time, learning, and meticulous attention to detail.

Outsourcing Pros & Cons: Outsourcing provides experience, especially for new payers, but can be expensive and may lead to less direct control or transparency on progress.

Meticulous Information Gathering is Key (Stage 1): The initial phase of collecting comprehensive practice and provider information (especially via CAQH) is the bedrock of your application; don't cut corners here.

Proactive Application Follow-Up (Stage 3) is Vital: Don't just submit and forget. Consistently follow up (e.g., every two weeks after initial confirmation) to track progress, resolve issues, and avoid delays in the "waiting game".

Review Your Contract Carefully (Stage 4): Once approved, meticulously review the payer contract for responsibilities, terms, compensation details (including fee schedules), timely filing, and credentialing identifiers before signing.

Start Date is Your Green Light (Stage 5): Your effective start date, not the contract signature date, is when you are officially in-network and can begin seeing patients and submitting claims for reimbursement.

Credentialing is an Ongoing Process (Stage 6): It's not a one-time event. Regularly manage and review your credentialing status through recredentialing/reattestation and keep your CAQH information updated every 6-12 months.

Understanding the Process Empowers You: Even if you outsource, understanding each stage of credentialing helps you manage expectations, ask the right questions, and ensures smoother overall RCM processes.

RESOURCES

Learn More About The Claim Game: Visit practicesol.com/podcast

The 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: We mentioned several images in today's Episode

Practice Payer List Image

The Six Stages of Credentialing Image

Is your practice tired of wrestling with insurance denials, deciphering EOBs, and watching your revenue slip through the cracks? You are not alone! Welcome to The Claim Game, the podcast designed to cut through the confusion and provide you with the best practices for revenue cycle management (RCM) success. Join Jeremy and Kathryn Zug as they simplify the complex landscape of RCM, explaining it as a game with rules that can be played well or poorly. They introduce the six key "territories" on the RCM game board: Credentialing, Patient Registration, Eligibility and Benefits, Payment Posting, Aging Follow-Up, and Claim Submission.

In this foundational episode, learn how credentialing is the crucial first step to even "get on the board" and why it can feel like an impossible hurdle for many providers. Discover why meticulous patient registration is vital for smooth billing and strong patient relationships, affecting everything from patient retention to claim rejections. The Zugs then detail Eligibility and Benefits (E&B), emphasizing its role in setting expectations for patient payment and the importance of checking it regularly, not just once. You'll understand the critical distinction between a claim rejection (from the clearinghouse) and a denial (from the insurance company) and why Payment Posting should always happen before Aging Follow-Up to avoid wasting time and money. Finally, they cover Claim Submission, highlighting the importance of completed clinical notes and strategic frequency.

Jeremy and Kathryn share their own journey of founding Practice Solutions in 2017 with the mission to remove the burden of billing and educate providers. They believe "you don't have to do it yourself, but it's not that hard to understand." Tune in to gain clarity, confidence, and practical tools to win at "The Claim Game" and return to focusing on patient care. "

KEYWORDS

revenue cycle management, insurance billing, credentialing, patient registration, eligibility and benefits, payment posting, claim submission, healthcare podcast, billing solutions, Practice Solutions

TAKEAWAYS

Credentialing gives you your "game piece": You can't even play The Claim Game without proper credentialing. It's the foundational step to becoming in-network with insurance partners.

Patient Registration brings players to the board: Meticulous patient registration, including collecting accurate ID and insurance information, is crucial to avoid claim rejections and build strong patient relationships. This also includes streamlining your checkout process.

E&B sets the expectations: Verifying Eligibility and Benefits ensures you and your patients understand coverage, deductibles, copays, and prior authorization requirements before services are rendered. This information should be checked regularly, not just once.

Payment Posting is about clarity: Always post payments before working your aging report. Understanding Explanation of Benefits (EOBs) and Electronic Remittance Advice (ERAs) through accurate payment posting prevents wasted time and helps identify fixable claim errors.

Aging Follow-Up tackles outstanding revenue: Proactively managing your insurance and patient aging reports, prioritizing older and larger balances, is essential to avoid timely filing write-offs and ensure consistent cash flow.

Claim Submission ensures accurate billing: A claim is ready for submission when the appointment is completed and the clinical note is finalized. Understanding the difference between a "rejection" (clearinghouse data errors) and a "denial" (payer issues) is key to efficient claims management.

Practice Solutions' Mission: We exist to empower providers by removing the burden of billing and educating on best RCM practices, aiming to provide clarity in a confusing industry

CHAPTERS

00:00 Introduction to the Claim Game

04:12 Round 1: Introducing the 6 Key Territories

04:31 Territory 1: Credentialing

10:27 Territory 2: Patient Registration

21:19 Territory 3: Eligibility & Benefits

30:21 Territory 4: Payment Posting

38:14 Territory 5: Aging Follow-up

44:53 Territory 6: Claim Submission

53:53 Case Study Card: The Birth of Practice Solutions

59:04 Conclusion to The Claim Game Podcast

RESOURCES

Learn More About The Claim Game: Visit practicesol.com/podcast

Terminology Guide: For a full list of RCM definitions discussed in this episode, check out our Frequently Used Billing Terms.

The 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: We mentioned several images in today's Episode6 RCM Domains Cycle Clean Claim Path

Helping Your Patients Understand Insurance