MULTI-SPECIALTY DENIAL PROJECT – INTERVIEW Q&A

MULTI-SPECIALTY DENIAL PROJECT – INTERVIEW Q&A

BASIC LEVEL (1–25)

1. What is a denial in medical billing?

A denial is when an insurance payer refuses to pay for a claim due to errors, missing information, or policy issues.

2. What is a denial project?

A denial project focuses on analyzing, correcting, and resubmitting denied claims to recover revenue.

3. What is RCM?

RCM (Revenue Cycle Management) is the process from patient registration to final payment collection.

4. What are common denial types?

• Coding errors
• Authorization issues
• Eligibility issues
• Medical necessity
• Duplicate claims

5. What is a soft denial?

Temporary denial that can be corrected and resubmitted.

6. What is a hard denial?

Permanent denial that cannot be reversed.

7. What is CARC?

Claim Adjustment Reason Code – explains why claim denied.

8. What is RARC?

Remittance Advice Remark Code – gives additional explanation.

9. What is medical necessity denial?

When payer feels service is not medically required.

10. What is timely filing denial?

Claim submitted after payer deadline.

11. What is duplicate claim denial?

Same claim submitted multiple times.

12. What is eligibility denial?

Patient not covered on date of service.

13. What is authorization denial?

Service done without prior approval.

14. What is bundling denial?

Services combined incorrectly (violates NCCI rules).

15. What is unbundling?

Separating codes that should be billed together (incorrect).

16. What is modifier?

Additional code element explaining special circumstances.

17. What is denial rate?

Percentage of denied claims out of total claims.

18. What is first pass resolution rate (FPRR)?

Claims paid without denial on first submission.

19. What is AR (Accounts Receivable)?

Money owed to provider.

20. What is aging report?

Shows outstanding claims by time (30, 60, 90 days).

21. What is write-off?

Amount provider cannot collect.

22. What is resubmission?

Correcting and sending claim again.

23. What is appeal?

Formal request to reconsider denied claim.

24. What is payer?

Insurance company.

25. What is EOB/ERA?

Explanation of Benefits / Electronic Remittance Advice.

⚙️ INTERMEDIATE LEVEL (26–60)

26. What is root cause analysis in denial?

Identifying main reason behind denial to prevent future issues.

27. What is denial prevention?

Fixing errors before claim submission.

28. What is coding denial?

Incorrect CPT/ICD codes.

29. What is modifier-related denial?

Missing or incorrect modifier usage.

30. What is POS denial?

Wrong Place of Service code used.

31. What is LCD/NCD?

Local/National Coverage Determination rules by Medicare.

32. What is medical necessity documentation?

Clinical records supporting treatment need.

33. What is upcoding?

Billing higher-level service than performed.

34. What is downcoding?

Payer reduces billed code to lower level.

35. What is DRG denial?

Incorrect diagnosis grouping in inpatient billing.

36. What is pre-authorization?

Approval before performing procedure.

37. What is COB denial?

Coordination of Benefits issue.

38. What is non-covered service denial?

Service not included in plan.

39. What is documentation mismatch denial?

Documentation does not support codes.

40. What is retrospective review?

Review after service provided.

41. What is appeal levels?

• Level 1
• Level 2
• External review

42. What is appeal letter?

Detailed justification to overturn denial.

43. What is reconsideration?

First-level appeal.

44. What is claim scrubber?

Software to detect errors before submission.

45. What is clean claim?

Error-free claim ready for payment.

46. What is denial trend analysis?

Tracking common denial patterns.

47. What is KPI in denial project?

Key metrics like denial rate, TAT, recovery rate.

48. What is TAT?

Turnaround time for resolving denials.

49. What is revenue leakage?

Loss of revenue due to errors.

50. What is coding audit?

Reviewing coding accuracy.

51. What is payer policy?

Rules defined by insurance.

52. What is appeal documentation?

Medical records, notes, reports.

53. What is claim lifecycle?

Submission → Adjudication → Payment/Denial.

54. What is zero payment denial?

Claim processed but paid $0.

55. What is underpayment?

Paid less than expected.

56. What is overpayment?

Paid more than expected.

57. What is denial management workflow?

Identify → Analyze → Correct → Appeal → Track.

58. What is revenue recovery?

Recovering denied payments.

59. What is front-end denial?

Error before claim submission.

60. What is back-end denial?

Error after claim submission.

🚀 ADVANCED LEVEL (61–90)

61. How do you handle medical necessity denial?

Review documentation, add supporting notes, submit appeal.

62. How to reduce denial rate?

• Proper coding
• Pre-authorization
• Eligibility verification

63. What is denial dashboard?

Tool to track denial metrics.

64. What is payer mix?

Different insurance types distribution.

65. What is escalation matrix?

Hierarchy for unresolved issues.

66. What is denial categorization?

Grouping denials by type.

67. What is appeal success rate?

Percentage of successful appeals.

68. What is automation in denial project?

Using tools for faster processing.

69. What is compliance in denial management?

Following regulations like HIPAA.

70. What is fraud and abuse?

Illegal billing practices.

71. What is OIG?

Office of Inspector General monitors fraud.

72. What is coding accuracy rate?

Percentage of correct coding.

73. What is productivity metric?

Claims handled per day.

74. What is quality audit?

Checking accuracy of work.

75. What is payer-specific denial?

Denial based on payer rules.

76. What is clinical validation denial?

Diagnosis not supported clinically.

77. What is DRG validation denial?

Incorrect DRG assignment.

78. What is retrospective denial?

Denied after initial payment.

79. What is appeal turnaround time?

Time to resolve appeal.

80. What is denial aging?

Time pending denial resolution.

81. What is revenue cycle optimization?

Improving entire billing process.

82. What is denial write-off vs appeal decision?

Evaluate cost vs benefit.

83. What is high-dollar denial?

Denial with high financial impact.

84. What is payer communication?

Interaction with insurance.

85. What is denial ownership?

Assigning responsibility.

86. What is rework rate?

Repeated corrections needed.

87. What is audit trail?

Record of changes/actions.

88. What is compliance risk?

Risk of violating regulations.

89. What is SLA?

Service Level Agreement.

90. What is benchmarking?

Comparing performance standards.

SCENARIO-BASED QUESTIONS (91–105)

91. Claim denied for no authorization – what will you do?

Check if authorization exists → attach proof → resubmit or appeal.

92. Medical necessity denied – action?

Add clinical documentation → appeal.

93. Duplicate denial – action?

Check claim history → correct submission.

94. Coding denial – action?

Correct CPT/ICD → resubmit.

95. Timely filing denial – action?

Check submission proof → appeal.

96. Underpayment – action?

Compare contract → appeal for balance.

97. Missing modifier denial?

Add correct modifier → resubmit.

98. Bundling denial?

Check NCCI → correct coding.

99. Eligibility denial?

Verify coverage → correct insurance.

100. High denial rate – what will you do?

Perform root cause analysis + training + process improvement.

101. How do you prioritize denials?

High dollar → aging → payer deadlines.

102. How do you handle multiple denials daily?

Use tracking tools + prioritize.

103. How do you ensure quality?

Follow guidelines + audits.

104. How do you communicate with team?

Daily reports + meetings.

105. What tools you use?

Excel, billing software, denial dashboards.

MANAGER LEVEL QUESTIONS (BONUS)

106. How will you manage denial team?

• Assign roles
• Monitor KPIs
• Provide training

107. How to improve team productivity?

Automation + training + tracking.

108. How to reduce revenue loss?

Denial prevention + faster appeals.

109. How to handle client escalation?

Analyze issue → provide solution → update client.

110. How to create denial strategy?

Data analysis + process improvement.

FINAL TIPS FOR INTERVIEW

✔ Focus on real-time examples

✔ Use keywords: denial, root cause, appeal, revenue recovery

✔ Show analytical thinking

✔ Speak in structured manner