Practice cases
Each one is a realistic, made-up claim. You decide what to do with it, then a veteran examiner shows you the right answer, the trap to watch for, and how to stop it next time.
32 of 32 scenarios
The claim that sat in a drawer
Everything on this claim is fine except one thing: it was filed too late. Learn the two dates a pro checks before anything else.
Covered yesterday, not today
A clean, well-coded visit you should still deny — because the patient's coverage had already ended. The gate that comes before everything else.
The claim that came back twice
The same claim shows up twice. Learn how examiners catch true duplicates — the most common way money quietly leaks out.
The line that won't pass edits
One field on this claim contradicts all the others. Learn to scan a claim the way pros do — for the value that doesn't fit.
The diagnosis that won't stand
A diagnosis code that isn't specific enough to pay a claim on. Learn to tell a real, billable code from a category header.
The copay that shouldn't be there
A copay charged on a visit that should have been free. Learn when preventive care means $0 for the patient.
The MRI nobody authorized
An expensive scan with no approval on file. Learn the step that has to come before you deny for 'no prior authorization.'
The E/M that came along for the ride
An office visit tacked onto a procedure that didn't really call for one. Learn to spot the most over-used billing add-on.
Two cards, one visit
The patient has two insurance plans. Before you pay as the second one, learn what you must confirm the first one did.
The denial that wasn't
The system flagged 'no authorization' — but a valid one is right there. Learn why a flag is a question, not a verdict.
The bill that beat the contract
An in-network provider billed full price. Learn why the only number that matters is the contracted rate, not the charge.
The units that don't add up
The drug code is right, but the units don't match the dose given. Catch the quantity error hiding in plain sight.
The day with too many hours
One visit looks perfect — until you add up the provider's whole day and the hours are impossible. Fraud that only shows from above.
Covered in the system, not on the date
The patient shows as active in the system, but wasn't actually covered on the visit date. Spot the gap a back-dated cancellation leaves behind.
Late on paper, on time in fact
The claim looks filed past the deadline — but when there's a second insurer, the clock starts somewhere else. Learn the exception.
The 59 that unbundled itself
A code used to force two bundled services to pay separately — when the records don't back it up. Catch the override.
Two panels, one draw
Two lab panels billed together — but one already contains the other. Spot the overlap you shouldn't pay for twice.
The duplicate that fixes an overpayment
It looks like a duplicate, but it's actually a corrected claim. Learn to tell a true double-bill from a fix you should process.
The office rate for a hospital procedure
Billed at the higher office rate for a procedure actually done in a hospital. Learn how the location sets the price.
The diagnosis that stops one character short
The diagnosis code looks right but stops one character short of what's required. Learn the small detail that fails the edit.
The newborn who 'isn't a member yet'
The system says the newborn 'isn't a member yet' — but they're covered. Learn the grace period behind a denial that would be wrong.
Who pays first for the working 67-year-old
The provider billed you second, behind Medicare. Learn how to check who actually pays first instead of just following their lead.
Cost-share after the out-of-pocket max
The patient already hit their out-of-pocket max — so the usual cost-sharing shouldn't apply. Get the math right.
The add-on with nothing to add onto
An 'add-on' charge billed with nothing to add it onto. Learn why some codes simply can't stand on their own.
The morning worklist
A morning queue of ordinary-looking claims. Practice sorting them fast and clean — the real skill of the production floor.
The panel that got taken apart
Four separate lab charges that are really one panel, split apart to bill more. Learn to read the whole claim as a shape.
The visit that came with a procedure
A visit and a procedure on the same day. Learn when billing both is genuinely justified — and when it's padding.
The ECG billed twice
Three valid heart-test codes that can't all be billed together. Catch the combination that charges twice for one test.
No auth on an emergency admission
An emergency admission auto-denied for 'no prior auth.' Learn when the rules bend for a genuine emergency.
Every visit is the most complex visit
One high-level visit seems fine — but this provider bills every patient that way. Learn to spot upcoding across a pattern.
Two surgeries, one session, full price twice
Two real surgeries in one session — but you can't pay full price for both. Learn how shared costs change the second one.
The suspense queue: pay or refer
A queue of held claims: pay them, or refer to investigators? Practice the judgment call in both directions.