🛡️
Module 5: Payers, Eligibility & Authorization
Do the front-end work that prevents most denials, and understand how payers decide what to pay.
2
Lessons
46
Minutes
Practice
Files Included
Intermediate
Level
What You'll Learn
- What an eligibility verification confirms, and what it does not
- The difference between coverage, authorization, and medical necessity
- Using an ABN and modifier GA for Medicare services that may not be covered
- Fee schedules, RBRVS, and why timely filing limits are absolute
Real-World Scenario
In Module 1 you found that 112 of last month's 138 denials originated before the patient was ever seen. Every one was preventable in the ninety seconds before the appointment. Meanwhile the same office visit code pays $186 from one payer, $142 from another, and $109 from Medicaid.
Lessons
Complete each lesson in order. Watch the video, review the notes, and finish the challenge.
Lesson 1⏱ 24 min
🛡️Eligibility Verification and Prior Authorization
Do the front-end work that prevents most denials, and understand the difference between coverage, authorization, and medical necessity.
Lesson 2⏱ 22 min
🛡️Payer Rules and Fee Schedules
Understand how payers decide what to pay, and why the same service produces different payments from different plans.