In this episode, we break down two commonly misunderstood terms in healthcare coverage: "Statutorily Excluded" and "Not Medically Necessary."

While they may sound similar, these distinctions have major implications for providers, payers, and—most importantly—patients.

We explore how these classifications affect insurance claims, appeal rights, provider obligations, and patient financial responsibility. Whether you're a healthcare administrator, clinician, or just navigating your own care, understanding this difference can help you advocate more effectively within the system.

• ✅ What "statutorily excluded" means under federal healthcare programs like Medicare

• ✅ How "not medically necessary" determinations are made

• ✅ Why the distinction affects patient billing and appeals

• ✅ Key compliance and documentation tips for healthcare providers

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• 1. Statutorily Excluded: Services never covered by law, regardless of medical need (e.g., cosmetic surgery under Medicare).

  2. Not Medically Necessary: Services denied based on clinical judgment or guidelines—even if technically covered.

  3. Appeal Rights: Patients typically cannot appeal statutory exclusions but can appeal denials based on medical necessity.

  4. Documentation Matters: Accurate clinical notes can be the difference between a denied and an approved claim.

  5. Proactive Communication: Providers should notify patients in advance using tools like ABNs (Advance Beneficiary Notices).

     
     

     
     

     Advance Beneficiary Notice (ABN) Guide

     
     

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Whether you’re a coder hunting for the right CPT, a tumor registrar assembling a perfect abstract, or a practice manager double‑checking documentation, that pathology report is gold— if you know how to mine it. In this episode Jennifer breaks down her go‑to process for turning dense, microscopic jargon into clean, billable data that tells the patient’s full story.

In this conversation you’ll learn:

• How to navigate the four must‑read sections of every path report (and why the microscopic description isn’t always the MVP).

• Pro tips for translating diagnostic phrases into precise ICD‑10‑CM codes—without over‑coding malignancy.

• When a single tumor can drive multiple CPTs (and when bundling rules shut that down).

• Common abstracting traps—margin language, laterality gaps, and “NOS” pitfalls—and how to fix them before they hit the claim.

• Simple query templates that get pathologists to clarify size, grade, or margins without slowing the lab down.

Loved the episode? Subscribe, leave a review, and share it with your favorite lab or HIM team.

Stress is inevitable, but burnout doesn’t have to be. In this powerful episode of Practice Perfect, Jennifer and Maya dive into the real reasons behind workplace burnout and what healthcare teams can do about it. From overloaded coders and overwhelmed managers to providers stretched thin, we explore what it takes to create a culture that not only survives—but thrives.

You'll learn:

• How to recognize the early signs of burnout

• Why stress doesn’t always lead to burnout—but poor systems do

• Real-world strategies to build calm into your workflows

• How leadership can set the tone for psychological safety

• Tools your team can use today to reduce chaos and improve morale

April is Stress Awareness Month, making it the perfect time to talk about how your team can reset, recharge, and reclaim productivity without sacrificing well-being.

If you’ve ever felt like your team is stuck in survival mode, this episode is your permission to make a change—and the roadmap to get there.

Hosts:

• Jennifer McNamara – Founder of Healthcare Inspired LLC, expert in compliance, coding, and revenue cycle management.

• Maya Turner – Owner of Turner Expert Consulting, passionate about helping practices thrive through expert guidance and simplified solutions.

  
  

Episode Summary:
In this episode, Jennifer and Maya bust some of the biggest myths surrounding payers. From payment delays to the misconceptions about small claim errors, they bring the truth to light with engaging facts and real stories. Listen in as they break down why you can—and should—negotiate with payers, and how to navigate common payer challenges for a healthier revenue cycle.

Key Topics Covered:

• Common Payer Myths:

  • “Payers never pay on time.”

  • “Small claim errors always lead to rejection.”

  • “You can’t negotiate with payers.”

    And lot's more...

• Facts to Set the Record Straight:

  • Causes of payment delays and what you can do about them.

  • The truth about claim rejections and how to handle minor errors.

  • Negotiation strategies that work with payers to secure better deals.

• Improving Your Payer Relationships:

  • How to use knowledge of payer myths to your advantage.

  • Building better payer relationships for improved revenue.

    
    

Featured Segments:

• Jennifer’s Insights: The real impact of payer myths on revenue and how to approach them.

• Maya’s Takeaways: Actionable tips for handling negotiations and improving payer relations.

  
  

Call to Action:
Stay tuned for the next episode, where we’ll uncover Abstracting from the Path Report. Learn essential abstraction techniques that can enhance accuracy and efficiency in medical coding. Subscribe, leave a review, and let us know your thoughts and questions!

Let's debunk those payer myths together!

Episode Summary:

In this episode of Practice Perfect Podcast, we break down the most overlooked yet crucial aspects of payer contracts. Are you leaving money on the table? Do you know when to negotiate, push back, or walk away? We’re diving into the must-know contract terms, red flags to watch out for, and insider tips to ensure you’re getting the best deal.

From understanding your leverage to why you should treat contracts like relationships (yes, sometimes you just need to walk away!), this episode is packed with practical advice, humor, and surprising insights to help your practice stay profitable and protected.

✅ Compare before you commit – How active comparisons and expert consultations can help you negotiate better contracts.
✅ Know your worth – If a payer doesn’t value your extended hours or patient care efforts, you CAN say no!
✅ Contracts aren’t forever – They’re like relationships—if it’s not working, don’t be afraid to walk away!
✅ Telehealth & reimbursement trends – What you need to know about chronic care management, remote patient monitoring, and compliance changes.
✅ Maximize your revenue – Smart ways to increase income beyond direct patient visits.

Next Up: Top Payer Myths – Fact vs. Fiction

Think you know payers? Think again! In our next episode, we’re busting some of the biggest myths, including:

🚫 "Payers never pay on time."
🚫 "Small claim errors always lead to rejection."
🚫 "You can’t negotiate with payers."

Join us as we separate fact from fiction and give you the tools to take control of your revenue!

📲 Follow us on all our platforms for more insights!

Episode Summary:

In this episode of Practice Perfect Podcast, we dive into the crucial role of quality assurance in coding and audits. Our guest, Robin Ingalls- Fitzgerald, joins us to discuss common coding errors, the impact of compliance, and why strong auditing processes are essential for healthcare organizations.

From modifier 25 and 59 issues to the challenges of telehealth, we uncover why consistent education, collaboration, and compliance are key to avoiding costly mistakes. Plus, we explore how outsourcing and coding support services can enhance accuracy and efficiency without replacing in-house teams.

Key Takeaways:

✅ Why audits matter – Identifying and preventing common errors before they become compliance risks.
✅ Telehealth regulations – The evolving landscape and its impact on coding and billing.
✅ Collaboration in coding – How external experts support practices without taking over.
✅ Common documentation mistakes – How small errors (like wrong laterality in orthopedics) can have big consequences.
✅ Education & training – The role of continuous learning in maintaining compliance and quality assurance.

Notable Quotes:

💬 "It’s not about taking over your team’s work, but supporting them in delivering accurate and compliant coding." – Jennifer Mcnamara
💬 "Compliance isn’t just about following rules—it’s about ensuring patients get the right care." – Robin Ingalls-Fuchs-Gerald

Don’t miss Episode 9, where we break down payer contracts and reveal what practices often overlook when negotiating with payers. Learn how to get the best deal and avoid costly mistakes! 💰📑

🔔 Subscribe, leave a review, and join the conversation!

📌 LinkedIn: Jennifer McNamara | Maya Turner | Robin Ingalls-Fitzgerald

Tune in now and take control of your coding and auditing process! 🎧

Episode Summary:

Medicare Advantage plans come with their own set of rules when it comes to prior authorizations and coverage determinations. If you’re navigating the complex world of Medicare Advantage compliance, this episode is for you!

Jennifer and Maya are joined by Richelle Marting to break down:
✅ How prior authorization requirements differ from traditional Medicare.
✅ Key regulatory updates practices need to know.
✅ Strategies to streamline the approval process and reduce denials.

Whether you’re a provider, administrator, or compliance officer, this episode will help you stay ahead of the ever-changing Medicare Advantage landscape.

🔹 Understanding Prior Authorization in Medicare Advantage:

• The difference between Medicare and Medicare Advantage rules.
• How denials and appeals work in Medicare Advantage plans.

🔹 Regulatory Compliance & Coverage Determinations:

• The latest updates on CMS guidelines for prior authorization.
• What documentation is required for approvals.

🔹 Improving Workflow & Reducing Prior Authorization Delays:

• Strategies to speed up approvals and reduce administrative burdens.
• Best practices to avoid claim denials.

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🔹 What Providers Need to Know About Coverage Policies:

• How to ensure services are covered under Medicare Advantage.
• Navigating exceptions and medical necessity requirements.

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💡 Richelle’s Legal Insights: Breaking down the must-know regulations for 2025.

🛠️ Jennifer & Maya’s Practical Tips: How to optimize workflows and stay compliant.

Don’t miss Episode 8, where we welcome Robin Ingalls-Fitzgerald to discuss the importance of quality assurance in coding and audits. Learn how accuracy impacts compliance, reimbursement, and financial stability! ✅

🔔 Subscribe, leave a review, and join the conversation!

📌 LinkedIn: Jennifer McNamara | Maya Turner | Richelle Marting

Stay ahead of Medicare Advantage regulations—tune in now! 🎧

Episode Summary:

The healthcare revenue cycle is evolving fast, and staying ahead of the curve is essential for financial success. In this episode, Jennifer and Maya welcome Vanessa Moldovan to break down the biggest trends, challenges, and opportunities in Revenue Cycle Management (RCM) for 2025.

From payment models to automation, we’ll explore how practices can adapt and thrive in an ever-changing landscape. Whether you're a practice manager, billing professional, or compliance expert, this episode is packed with valuable insights to future-proof your revenue cycle. 💰

🔹 Emerging Trends in Revenue Cycle Management:

• How AI and automation are reshaping billing and collections.
• The impact of value-based care on reimbursement strategies.

🔹 Biggest Challenges Practices Face in 2025:

• Dealing with payer complexities and reimbursement delays.
• The rising demand for compliance in billing and coding.

🔹 Opportunities to Improve Financial Performance:

• Strategies for reducing denials and optimizing claims management.
• How data analytics can improve financial decision-making.

🔹 The Role of Patient Engagement in RCM:

• Improving price transparency to reduce surprise billing.
• Creating a smoother payment experience for patients.

💡 Vanessa’s Take: Key predictions for the future of RCM and how to prepare.

📊 Jennifer & Maya’s Insights: Practical steps to strengthen your revenue cycle today.

Call to Action:

Join us for Episode 7, where we welcome Richelle Marting to discuss Medicare Advantage requirements for prior authorization and coverage determinations. Gain clarity on the process and stay compliant with key regulations!

🔔 Subscribe, leave a review, and share your thoughts!

📌 LinkedIn: Jennifer McNamara | Maya Turner | Vanessa Moldovan

Let’s take control of the future of RCM together! 🚀