Most revenue cycle teams are chasing the wrong fire. Persistent underpayment, denials that don’t respond to appeals, patterns nobody can explain — these are often contract problems wearing a billing problem’s disguise.
In this episode, Alex breaks down the structural gap between contracting and RCM that costs providers real money every day, and delivers three things you can take to your next denial review right now.
WHAT YOU’LL HEAR
- The real story behind a multi-specialty group underpaid for 12 months — and why their billing team did nothing wrong
- Why contracting and RCM live in separate worlds — and why that gap is your biggest revenue risk
- Fee schedule effective date clauses: the most dangerous amendment language in managed care contracts
- Carve-out clauses and why behavioral health denials keep looking like coding errors
- Contract dispute timelines vs. your denial management cycle — what happens when they don’t match
- The one question to add to every denial review
THREE THINGS TO APPLY NOW
- Check your fee schedule effective dates. Know the execution date on every amendment. Confirm your billing system actually flipped to the new rates. 73% of providers don’t know what they’re contracted to receive.
- Map your carve-out clauses. Know which services are excluded from the base agreement and where those claims need to route — behavioral health is the most common gap.
- Find the contract dispute window in every active agreement. If it’s shorter than your internal denial cycle, that’s a configuration problem costing you money today.
THE DIAGNOSTIC QUESTION
When a denial pattern doesn’t respond to standard appeals, ask: Is this a billing problem or a contract problem? They need entirely different escalation paths. If your team is routing both into the same queue, contract-based underpayments are being written off — silently.
GO DEEPER: HBMA WEBINAR — AUGUST 12
Alex presents the full framework — denial categorization methodology and a contract audit checklist — live through the Healthcare Business Management Association (HBMA). 1 CEU credit available.
Register: https://www.hbma.org/meeting_calendar/details.php?event=3148
Checklist directly: vbcapodcast.com
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