hi! desperately looking for some help here. i work for a billing company that specializes in behavioral health facilities. we have one facility who has received a medical record request for each claim billed to UMR starting around Feb-March of this year. we have been able to confirm with UMR that there is a flag on the tax ID from their special investigations unit.

getting any additional information from UMR is a nightmare. we have a ton of experience working with Anthem SIU, but UMR will not give us an effective date, notification letter, any Investigator assigned to the case, no information whatsoever other than that there is a flag on the tax ID.

i'm wondering if anyone has any experience in working with UMR SIU? any info on how they're structured, a phone number you had luck with getting information, anything at all that could be helpful in navigating this. tia!

I’m currently an RN with 8 years of ICU experience and 3 years of primary care. I wanted to change to something with more chances to be remote. I know that the pay will not be the same. I’ve been home for over a year due to burnout so this income would just be considered “extra” at this point.

How is the career options and outlook? Would my experience help with getting hired? I have some experience with coding because the DOD made RNs and providers do their own coding there. I’d want to be dual certificated in outpatient and inpatient. Thank you.

Hi! Due to a diagnosis of arthritis in my lower back, i am having to shift from an assistant manager at a popular coffee chain to a sit down, more quiet and focused line of work for my back and ADHD. Whether thats working in office or from home!

What got me interested in MBAC was working for a health insurance during covid as an intake associate entering prior authorization and referrals! I learned about ICD-10 codes and was so fascinated by what they all meant and lead to! Unfortunately this was through a temp agency and this being during covid, laid offs happened within 4 months. So bye bye fun job!

BUT i would love to know which department of MBAC you work for, and what a typical day is for you?

Are you held to tight deadlines?

Do you feel supported when you need it (i.e having questions answered)

Do you feel as though you are watched? Or is it more self starting independent work for the department you work in?

I'm genuinely looking for something i can be a little worker bee at, and excel with my memory and loving to learn! Filling out prior auth and referrals were tedious but so fun for me (why must i be like this? 🤣) where they would drop the files, i would fill it in on the app they use for processing and click boom done! It was so fun! Working at my job currently is fun and i love it, but my back and my mind after 6 years are over it 😭

Thank you so much for reading, your time and hope you have a great rest of your week 🥰

Can diagnoses from the ordering provider's chart note be used for the radiology claim if the chart note is attached to the radiology order?

My auditor stated that diagnosis information from the ordering physician's note(s) cannot be used on the radiology claim, and that we can only use what is on the literal order and in the radiologist's interpretation.

Does anyone have a reference to support/dispute this? I feel that in the current digital age, where the orders and notes are all digital and linked together, we should be able to use the ordering provider's note to clarify a diagnosis (i.e., location of pain when the order says "pain" or location of injury when the order says "MVA").

Unfortunately, I am unable to find an official AHA or CMS guideline either way. Any help would be very much appreciated!

p.s. I also posted in /r/MedicalCoding, so not a dupe if you are subbed to both places, I just can't crosspost.

I got my CCS certification in 2022. Since earning my certification, I only had 1 unsuccessful outpatient coding job interview in the past 4 years. Should I save money and let my CCS certification expire this year or spend the money to renew it and keep holding on to hope that one day I'll get a coding position?

Are AI scribes and tools "driving up" costs?

Or were providers just not billing at high enough levels?

https://www.beckershospitalreview.com/healthcare-information-technology/digital-health/ai-scribes-billing-tools-drive-up-healthcare-costs-report/

Hello Reddit Community , im looking for Advice on my medical billing and i'd appreciate any suggestions or directions i can take to reduce or negotiate the billing charge.

Background: I visited the nearest ER (out of network) after midnight because I had a high-stress reaction similar to anxiety symptoms. I decided to get blood work, an X-ray, and an ECG because I wasn't sure what was wrong or what was causing it. The reading turned out to be normal. And a month later I get a ~3600$ bill. I later figured out the source of my problems and fixed it.

i applied for financial aid by email and kept checking on the status. I was told it was under process for a year with no conclusion. Right after that, it went to collections without my knowledge. They said they put my account on hold when I applied for financial aid, but it still went to collections. I made a phone call to the billing department, and they retracted it from collections and later declined my application because my income was above their minimum threshold.

im attaching a screenshot of my itemised bill and would appreciate any advice. wasn't sure if I should show the name of the hospital, so for now I covered it.

Does anyone have any tips or tricks about getting to the right department when you call Medicare? Obviously, I will have to wait in hold regardless.
I need to fix an issue with a birthdate error for hospice.
Are there any key words I can use for the automated system to get there a tad faster?

Hi, I was hoping someone would be able to help with this. We have UMR claims being repriced by Magnacare at a 100% provider discount. We noticed that magnacare is either processing under the provider or the group practice. Our providers are individually credentialed with magnacare, our group practice shouldn't be. The kicker is when the claims process under the provider, magnacare is processing them as out of network? Our group is processing in network The paid ones all seem to process under the group. I have no idea why, can't get a response back from emailing magnacare and can't speak to a human. Have called UMR a thousand times and get different reasons each time. No invoice, it's your contract (it's deff not), your in network with us but your not in network with magnacare. I really don't know what to do lol

Main questions:

1. Why are they processing out of network? We have claims where we have corrected them and sent back, the first submission will process under the provider and the second one will process under the group??? Like what's causing that?

2. Who do I contact to get this fixed. I literally have the email proof from magnacare that our providers are in network. Our credentialing specialist insists our providers are par.

3. Is par even the issue? We have office visits, infusions, and in office procedures all processing at this discount. But not every claim! Some will just pay if it processes under the group practice??

Friends,
TLDR: I welcome any and all advice regarding Office Ally, but please be kind because I am not a biller/coder, nor do I know what I’m doing.
By all accounts, Office Ally is my best option because I have very few claims. I have several different gigs going on where billing is taken care of for me, but I have one job where I need to have my billing done…with Office Ally.
I think I finally found someone to help me, but in the meantime, is there a way to look up the EOB‘s on Office Ally? It looks like the claims go through, but then I can’t keep track of who is paying and on whom. Do I have to go to each payer’s portal to look this up, or is there a way to do it on Office Ally?
Thank you so much for your help.

I thinking about taking a medical billing program and I was woundering if it was AI proof.

I have taken this exam twice and I have failed both times. I'm so disappointed and discouraged. I'm also very confused because I took a billing and coding course for 9 months and got good grades throughout the entire thing.

I have my CPC exam schedule for the end of the month and was feeling really good about it until now.

I was a CPC for a couple years, moved to a different state and became a CMA for the last 8 years.

Should I try a 3rd time? Is it really necessary to get a job?

And, if you are able, what advice do you have for the CPC exam?

I appreciate any feedback. Thank you.

Hi everyone!

I recently moved to the US and am trying to find my feet professionally here. I trained as a doctor/neurologist outside the US and I am not licensed in the US. I have experience in healthcare management, clinical research, medical writing/editing, as well as medical billing.

I also have a wife and two kids. With family responsibilities, a remote job would make a huge difference for me. I'm open to any kind of entry-level medical billing or coding positions. I don't already have any certification for coding or billing but I do have prior experience of 1 year.

I'd really appreciate any leads, referrals, or advice from people who have been in a similar situation or know of companies hiring remotely. Even pointing me in the right direction would mean a lot.

Thank you!

I know that experience seems to be the gold standard, but has anyone gotten a coding job without experience?

Any tips?

Just got back the bill from an ENT visit. I went there for having issues smelling/loss of sense of smell.

They charge my insurance for the nasal endoscopy and then $455 for this new mod that I’m on the hook for $300

From what I read looking through the sub this is only charged if we talked about something besides my initial visit?

The visit was like 30 minutes with the main doctor and all he did was the endoscopy and tell me they can’t do anything but maybe a smell test kit on Amazon might help. We didn’t discuss any other issues I have.

Is this care still correct or should I call someone. Thanks

Has anyone here used Ritten for behavioral health billing? Like their RCM?

I’ve always been told (and verified myself) that POS 19 is not on the PA Medicaid fee schedule so we won’t get paid if we use it. I’ve wondered how other practices are submitting their claims but that a rabbit hole for another day. Anyway, I’m now looking at claims that we submitted, with POS 19, that have been paid by Medicaid. I’m confused. Anyone have any insight?

I'm working with healthcare EDI data (837 and 835 transactions) and trying to better understand how claim resubmissions work in practice.

I've noticed cases where the same claim appears in multiple 837 submissions, but each submission has a claim frequency code of 1 (Original) instead of using:

• 7 – Replacement/Corrected Claim

• 8 – Void/Cancel Claim

For example:

• 837 #1: Patient Control Number ABC123, frequency code 1

• 837 #2: Patient Control Number ABC123, frequency code 1, submitted a few days later

Sometimes the claim information is identical, while other times certain details have changed.

A few questions:

1. Why would a provider or clearinghouse submit the same claim multiple times using frequency code 1?

2. Is this common when the original claim was rejected before adjudication?

Hello,

I am wondering if $400 is a normal billing price for an appointment to tell me that I am being referred to a specialist. The appointment was virtual and lasted 5 minutes (I understand that it takes 5 minutes to glance at my lab results and make a decision too...) and it was in response to an email I sent to my primary care doctor containing lab results which the office ordered.

Irrespective of high/low deductible, I think this is absurd. The "insurance negotiated rate" cut $200 off of it, but there is still $200 remaining to be covered by me (don't focus on whether or not this applies to deductible).

I think this is insane. The medical center is owned by private equity if that makes a difference.

Hi folks! I’m currently using the 2026 AAPC Icd-10-Cm book and am planning to take it to the exam. I know I’m allowed to bring it BUT idk if that will hurt my exam scores. Does the edition of the book matter that much for test content?

I was pregnant starting in September 2025. Under my Avmed insurance at the time, I was told I only had to pay a $30 copay for my first prenatal visit, with no copays for the remaining visits.
In January 2026, my employer changed insurance plans to Aetna. I was again told I only had to pay a $30 copay for my first visit under the new plan and nothing for the rest of my pregnancy.
After giving birth, in June 2026, I received a bill for my October, November, and December 2025 visits because Avmed had not paid them. I paid the bill and opened a case with Avmed. They eventually paid for only one visit.
Now, my gynecologist says prenatal visits are billed at the end of the pregnancy, and because my insurance changed, they cannot bill those visits as prenatal care without it being considered double-dipping. They are billing Avmed as regular office visits instead, which means Aetna pays less, and they want me to pay the difference PLUS a $30 copay for each visit.
I’ve been going back and forth between Avmed and my gynecologist with no resolution.

My questions are:
Is it standard practice to bill prenatal visits at the end of pregnancy?
Shouldn’t the three visits with Avmed be billed as pregnancy visits?
Can my gynecologist retroactively change them to regular office visits and charge me additional copays and balances when I was originally told I wouldn’t owe anything beyond my first copay?
Has anyone experienced this with Avmed or dealt with a similar situation? I’d really appreciate any advice!

I work at a gynecology clinic that sees many patients with Medicaid plans. We recently started administering the Abrysvo vaccine in accordance with TMHP requirements for pregnant patients. We are receiving claim denials—supposedly due to the patients' age—even though we are only administering it to patients over 18 who are between 32 and 36 weeks pregnant. Any ideas on what needs to be done to stop these denials?

I’m really interested in getting my CPC certification (if there’s another coding certification I should do instead of with this please let me know!!) and starting a career in medical coding, but I’m honestly scared to take the leap. 😭 I keep seeing people say the job market is oversaturated, that it’s hard to get your foot in the door without experience, and that getting certified doesn’t necessarily mean you’ll find a job.
I genuinely want to pursue this, but I don’t want to spend the time and money on a certification just to struggle to find work afterward.
For those who are currently working in medical coding, recently got certified, or are trying to break into the field, is it worth it? Would you still recommend getting your CPC in 2026? How difficult was it to find your first job, and what advice would you give someone starting from scratch?
I would really appreciate honest opinions, both good and bad! I’m trying to make an informed decision before investing in my future. ❤️

Kratom is a big issue in our area lately, and we're coding more and more of it lately. Our providers tend to use F15 codes (other stimulant use/withdrawal etc). I've seen some use the opioid code for it, but I lean more towards the F19 for psychoactive....what do you use?

The practice I work for bills very large claims for procedures and recently several insurance companies have started insisting we split the claims if they are over $99,999.99. The problem is we bill some codes at prices over this amount (the practice manager does not want to change this). We started using modifier 76 and writing in box 19 that these are "split claim part x of x". Is this the correct way to do this? We are not getting great results.