| Claim ID | Patient | CPT / ICD-10 | Payer | Charge | Denial Risk | AI Status |
|---|
CPT 27447 (Total Knee Arthroplasty) requires prior auth for UnitedHealthcare. None found in record.
Bilateral modifier -50 applied but documentation supports unilateral procedure. Likely denial trigger.
ICD-10 M17.11 (Primary osteoarthritis, right knee) — clinical notes reference conservative treatment history but no structured documentation of failed alternatives.
| Payer | Claims Processed | Denial Rate | Top Denial Reason | Avg Resolution | AI Recommendation |
|---|---|---|---|---|---|
| UnitedHealthcare | 2,847 | 14.2% | Prior Authorization (38%) | 32 days | Pre-submit auth check enabled |
| Aetna | 1,923 | 9.8% | Medical Necessity (42%) | 28 days | Documentation template updated |
| Blue Cross Blue Shield | 3,156 | 6.1% | Coding Errors (31%) | 21 days | Auto-validation active |
| Cigna | 1,482 | 11.3% | Eligibility (29%) | 35 days | Real-time eligibility check added |
| Medicare | 4,291 | 4.7% | LCD/NCD (45%) | 18 days | Coverage determination pre-check |
187 claims paid below contracted rate for CPT 99213-99215. Variance detected: -$42.30 avg per claim.
Clinical documentation supports 99214 but 99213 was billed on 94 encounters. Estimated uplift: $3,760.
Lab and imaging charges missing from 63 surgical encounters. Total identified: $28,420.
Based on the simulated analysis of a mid-size health system processing 13,699 claims per quarter.
Pre-submission scoring with 94.7% accuracy. Auto-fix for authorization, coding, and documentation gaps.
Autonomous identification of underpayments, undercoding, and missed charges. $2.3M annual recovery potential.
Real-time payer behavior analysis across 340+ rules. Contract compliance monitoring and auto-appeals.
72% auto-resolution rate. AI-driven triage replaces manual worklists. 18-day A/R improvement.