Work denied claims. Reduce authorization backlog.
Community practices need focused capacity around denied claims, prior authorization delays, and documentation gaps without disrupting daily billing or patient-facing work.
Services scoped to what you actually need.
We define the scope and the pricing before any work begins — so each engagement fits your accounts and your team, not a fixed package.
The method
A system for specialty reimbursement.
The setting determines the work.
Clients may face the same payer, but not the same records, deadlines, or upstream handoffs.
We review recent denials and prior authorization backlog to identify recovery opportunities, documentation gaps, and the appropriate next action for each issue.
Initial review: 3–5 business daysRecovery starts with triage.
A denied claim doesn't always need a formal appeal. Some should be corrected and resubmitted; others need a different path entirely.
Public Medicare Advantage data shows why route selection matters: KFF reported that 11.5% of denied prior authorization requests were appealed in 2024, and 80.7% of those appeals were partially or fully overturned.
01Correct / Resubmit
For missing information, claim-format issues, demographic errors, modifier or coding mismatches, and payer edits where a corrected claim is the cleaner path.
02Appeal
For medical necessity, experimental / investigational, coverage-criteria, or policy disputes when the documentation supports formal payer review.
03Payer / PA Follow-Up
For authorization mismatches, pending reviews, additional-information requests, or payer status issues that need targeted follow-up before escalation.
04Prevent the Next Recurrence
For patterns tied to ordering documentation, payer policy, network status, plan behavior, or repeat submission gaps that should be fixed upstream.
Useful starting points
Operational notes on claim routing and order readiness.
What Every Engagement Includes
These aren't add-ons — they're part of how we structure each engagement.
Defined scope & pricing
Scope and pricing are agreed before any work begins — no open-ended engagements.
BAA before PHI
A business associate agreement is executed before any protected health information is shared.
Monthly reporting
Appeal outcomes, payment activity, authorization turnarounds, and denial trends.
Focused reimbursement context
Oncology clinic and lab reimbursement workflows — not broad general billing.
What We Need From You
Enough access and context to work accurately, without a drawn-out implementation.
01
Scope Alignment
The service focus, payer mix, denial types, and expected workflow are defined before review work begins.
02
Secure Data Access
After a BAA, access to denied claims or requisition data is shared through an approved secure process.
03
Clinical Documentation
Medical records, lab results, orders, and physician notes needed to support medical necessity or claim correction.
04
Billing Team Contact
A single point of contact from your billing team for questions, coordination, and status updates.