PMRP common mistakes
PMRP · Understand the traps and how to avoid them.
Treating gross and net revenue as interchangeable when computing collection ratios, so the candidate divides cash collections by gross charges and reports a percentage far below any realistic benchmark.
Gross charges vary with chargemaster pricing strategy and bear little relation to expected reimbursement, so the resulting ratio looks alarming but is meaningless. Candidates default to the number printed largest on the report instead of the contractual allowance-adjusted figure.
What to do instead
Before any ratio calculation, identify the denominator explicitly: net revenue = gross charges minus contractual allowances and discounts. Memorize that net collection rate = cash collected / net revenue, and that gross collection ratio is only used for chargemaster and pricing analysis. Practice by restating a sample report line by line into gross, allowances, net, and cash before computing anything.
Applying Medicare timely filing (one calendar year from the date of service) to every payer, and appealing denials past a commercial payer's much shorter window.
Medicare's rule is the one most often taught and remembered, so candidates generalize it. Commercial contracts commonly set 90 to 180 days, and some Medicaid programs differ from Medicare as well.
What to do instead
Anchor on the principle that timely filing is payer- and contract-specific, then verify per payer: Medicare fee-for-service generally one calendar year from the date of service, Medicare Advantage per plan, commercial per contract, Medicaid per state. For appeals, distinguish the filing deadline from the appeal deadline, which is separate and often shorter. When a question gives no payer, state the assumption explicitly.
Registering a patient under an existing or newly created record without a patient identifier search, producing duplicate medical record numbers.
Speed pressure at the front desk plus common names, hyphenated surnames, and patients who cannot recall prior visits encourage skipping the search. Candidates also assume the EHR's demographic match is sufficient without verifying two identifiers.
What to do instead
Describe the standard workflow: search by at least two identifiers (full legal name plus date of birth, and where available SSN or prior MRN) before creating a record, use enterprise master patient index (EMPI) checks, and route suspected duplicates to health information management for merge rather than creating a new record. Note that duplicate MRNs fragment the chart and cause split claims and misattributed results.
Quoting a patient's out-of-pocket estimate from gross charges or from the allowed amount without applying deductible, coinsurance, and out-of-network status in the correct order.
The sequence of benefit accumulation is easy to state and easy to botch under time pressure. Candidates forget that copay and deductible are applied before coinsurance, and that a patient who has met part of the deductible owes only the remainder.
What to do instead
Work the arithmetic in a fixed order every time: allowed amount, minus remaining deductible, then apply coinsurance to the balance, then add any fixed copay per plan design, and cap at the out-of-pocket maximum. Always verify eligibility and benefit accumulation in real time and document the estimate and its assumptions. Show the calculation steps in the answer rather than only the final dollar figure.
Assigning an ICD-10-CM diagnosis code that is clinically consistent with the note but unsupported by documented specificity, such as coding an unspecified diabetes code when the documentation names the complication, or the reverse.
Candidates read the assessment impression and code from memory of the disease rather than from the documented detail. ICD-10-CM demands laterality, episode of care, and complication specificity that narrative notes often omit.
What to do instead
Code only what is documented and query the provider when specificity required by the code set is absent. In CDI questions, the correct action is usually a compliant physician query, not an inferred code. Practice by taking a short note, listing every codeable concept, and marking which required specificity elements are missing and must be queried.
Assuming that a claim rejected at the clearinghouse was adjudicated and denied by the payer, and counting it in the denial rate or appealing it.
Front-end rejections and payer denials look similar in a work queue but occur at different stages. Candidates conflate them and then misclassify metrics, which inflates denial rates and sends appeals where no claim exists.
What to do instead
Separate the two: a clearinghouse rejection means the claim never reached the payer (edit failure, missing data, format error) and is corrected and resubmitted, not appealed; a payer denial is an adjudicated claim with a remittance advice and appeal rights. When reviewing a remittance, confirm the payer claim control number exists before treating the item as a denial, and classify root cause at the point of failure.
Writing an appeal that restates the original claim and demands reconsideration without citing the specific denial reason, the supporting documentation, or the plan or policy provision being relied on.
Appeals are often produced from a template under volume pressure. Candidates also believe the clinical record speaks for itself, so they attach records without pointing to the page or element that rebuts the denial.
What to do instead
Structure every appeal as: the denial code and its stated reason, the factual rebuttal with a pinpoint reference to the record, the contract or coverage policy language or coding guideline that supports payment, and the specific remedy requested. Match the appeal level to the payer's process (first-level reconsideration versus peer-to-peer versus external review) and track the appeal deadline separately from the filing deadline.
Reporting days in accounts receivable using total gross charges in the numerator instead of net revenue, or measuring AR from the discharge date rather than the first billing date.
Both versions appear in the literature and in vendor reports. Candidates pick one without stating which and then compare it to a benchmark built on the other, producing a false conclusion about performance.
What to do instead
State the formula and its basis explicitly: days in AR = (total AR / net revenue) x days in period, with the period matching the revenue figure. Note that using gross charges overstates days in AR and that measuring from discharge includes coding lag, while measuring from first bill isolates collection performance. Always name the basis when comparing to a benchmark.
Posting an insurance payment to the patient responsibility bucket or leaving an unapplied cash balance rather than reconciling the remittance line to the expected contractual allowance.
Auto-posting rules and contract modeling fail on outliers, and candidates treat posting as data entry rather than as the control point where contractual allowance accuracy is tested. Unapplied cash then hides as a reconciling item.
What to do instead
For each remittance line, verify allowed amount against the contracted rate, post the contractual adjustment to the correct adjustment reason code, and post only the true patient responsibility to the patient ledger. Investigate and clear unapplied cash within a defined window, and reconcile the bank deposit to posted batches daily so that a variance is caught while the remittance is still at hand.
Treating a metric in isolation, such as celebrating a falling days-in-AR while initial denials and write-offs rise, instead of reading the revenue cycle as a linked set of indicators.
Dashboards present metrics side by side and candidates answer about the single number named in the question. They miss that aggressive write-offs and faster cash can both flatter AR metrics while destroying net revenue.
What to do instead
Analyze in causal chains: front-end accuracy drives clean claim rate, which drives denial rate, which drives AR days and write-offs. When a metric improves, ask what offsetting metric moved and whether the change came from real process improvement or from write-offs, payment shifting, or changed denominators. In scenario questions, name the paired metrics you would check before concluding.
Sharing or transmitting protected health information through unapproved channels, such as emailing a spreadsheet of patient accounts without encryption or discussing a case in a public area, because it feels operationally convenient.
Candidates separate 'security' from 'getting the work done' and assume that internal recipients are automatically authorized. Minimum necessary and channel-approval rules are treated as IT's problem rather than the workforce member's obligation.
What to do instead
Apply minimum necessary to every disclosure: limit the data elements, confirm the recipient's authorization to receive them, and use only approved encrypted channels. Remember that HIPAA permits but does not require email, so the covered entity's policy governs; unencrypted email of PHI is generally a reportable risk unless a documented exception applies. Treat a suspected breach as a notification-timeline question, not an IT ticket.