Wednesday, August 12, 2026 • 11:00 AM PT / 2:00 PM ET • 60 minutes • 1 CHBME Credit
The Problem Isn’t the Claim. It’s the Contract.
Every revenue cycle team has a version of the same story. Claims go out clean. Denials come back anyway. Payments arrive at the wrong rate. EOBs reference fee schedules that don’t match what anyone signed. The appeal process starts, but something always feels off — like you’re fighting a problem that shouldn’t exist.
In most cases, you are.
The root cause isn’t a coding error. It isn’t a late submission. It isn’t a payer processing mistake. It’s a provision in a contract that was signed months or years before the first patient was ever seen — a provision nobody flagged at the time, that has been quietly generating billing problems ever since.
This is the central premise of the HBMA webinar Your Billing Problem Started in the Contract, presented by Alex Yarijanian on August 12, 2026. The session draws on seven years of managing payer contracting operations for more than 600 provider organizations across all major commercial insurers, Medicaid managed care plans, and Medicare Advantage organizations nationwide.
Why Billing Teams Can’t Solve Contract Problems
There is a structural reason revenue cycle teams struggle with certain categories of denials and underpayments: they are attempting to resolve at the billing stage a problem that was created at the contracting stage. The tools available to billing teams — appeals, corrected claims, secondary billing, peer-to-peer reviews — are designed to address adjudication errors. They are not designed to address contract ambiguities, outdated fee schedule references, or missing provisions.
When a payer denies a claim citing a contract exclusion, billing cannot override the contract. When a payment arrives at a rate that reflects a fee schedule version the organization never intended to accept, appeals often go nowhere because the payer is, technically, paying what the contract says. When coordination of benefits language is vague, secondary billing becomes unreliable because no one can predict which insurer will be assigned primary responsibility for which claim.
These are not billing problems. They are contract problems with billing consequences. And they require a different kind of intervention.
Five Contract Provisions That Generate Systematic Billing Failures
The session will examine specific contract provisions that most commonly produce downstream billing and reimbursement failures. Among the areas covered:
1. Fee Schedule Effective Date Language
Payer contracts frequently reference a fee schedule by name without specifying which version applies at the time of service, or how and when updates are communicated to the contracting party. When a health plan updates its fee schedule mid-contract cycle, provider organizations may continue billing against rates they believe are current while the payer adjudicates at the updated schedule — or vice versa. The discrepancy often goes undetected until a systematic underpayment audit surfaces it months later.
2. Carve-Out Clauses and Service Exclusions
Carve-out provisions exclude specific service lines, procedure codes, or patient populations from the contracted rate structure. These clauses are common in Medicaid managed care and Medicare Advantage contracts and are frequently buried in exhibits or addenda that receive less scrutiny during initial contract review. When billing teams submit claims for services that are silently carved out, the denials that result are often miscategorized as coding errors or authorization failures — when the actual issue is a contract-level exclusion that nobody caught.
3. Coordination of Benefits (COB) Terms
COB language in payer contracts determines how the plan interacts with other coverage when a patient has dual insurance. Ambiguous or poorly drafted COB provisions create uncertainty about primary and secondary payer responsibility, which cascades into billing errors, delayed payment, and write-offs on claims that should have been collectible. When COB terms conflict between the commercial contract and the Medicare Advantage or Medicaid plan contract for the same patient population, the results are predictably difficult to resolve at the claims level.
4. Timely Filing Windows and Appeals Procedures
Contract-specific timely filing deadlines and appeals procedures frequently differ from payer standard policies and from CMS requirements. When revenue cycle teams apply a generalized filing and appeals calendar across all payers — rather than tracking the specific contractual deadlines for each agreement — claims are lost to timely filing denials that would have been avoidable, and appeals are submitted into the wrong process at the wrong stage.
5. Most-Favored-Nation (MFN) and Downward Rate Adjustment Clauses
MFN clauses and automatic rate adjustment provisions can reduce contracted rates without requiring a formal renegotiation or even explicit notice, depending on how the contract is drafted. Provider organizations that do not conduct periodic contract compliance audits often discover these adjustments only when systematic underpayment analysis surfaces an unexplained rate reduction. At that point, the recovery window may have narrowed considerably.
A Framework for Separating Billing Problems from Contract Problems
One of the core deliverables of the session is a practical framework for distinguishing between three categories of denials and underpayments:
- Clinical denials — medical necessity, authorization, documentation deficiencies. These are resolved through clinical appeals, peer-to-peer reviews, and documentation improvement programs.
- Administrative denials — timely filing, eligibility, billing errors. These are resolved through claims process corrections, eligibility verification workflows, and staff training.
- Contract-based denials and underpayments — rate discrepancies, excluded services, COB failures, fee schedule mismatches. These require escalation outside the billing function, into formal contract dispute procedures, renegotiation, or regulatory complaint channels.
Routing contract-based issues through clinical or administrative appeal pathways is one of the most common and costly mistakes in revenue cycle management. It consumes staff time, fails to recover the revenue, and delays the contract-level intervention that would actually resolve the pattern
About the Speaker
Alex Yarijanian is the founder and Chief Executive Officer of Carenodes, a healthcare contracting and network management company that has facilitated payer-provider contract negotiations for more than 600 provider organizations across all major commercial insurers, Medicaid managed care plans, and Medicare Advantage organizations nationwide. He previously served as a regional contracts and networks executive at Humana Health Plan and held management roles at HCA and Dignity Health. He has served on select committees for the California Department of Managed Care, the Florida Department of Public Health, and the North Carolina Department of Justice, and hosts the Value-Based Care Advisory Podcast.
Register for the Webinar
Your Billing Problem Started in the Contract
Wednesday, August 12, 2026 • 11:00 AM PT / 2:00 PM ET
60 minutes • 1 CHBME Credit
Member: $49 | Non-Member: $99
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