What recovery work looks like, claim by claim.
Four client engagements covering the problems we fix most often: anesthesia modifiers, unusual-anesthesia billing, Texas state complaints and contract underpayments in spine. Names are withheld to protect client confidentiality.
Results at a glance.
Recovered revenue, fewer denials and faster payment for independent procedural practices. Client and physician names are kept confidential.
Fixing anesthesia modifier errors and recovering out-of-network underpayments
A multi-provider anesthesia group billing out of network was seeing repeated denials and short payments. Revenue was slipping and staff were spending hours on rework.
What we found
- Medical direction and supervision modifiers (QK, QX, QY, QZ, AD) reported without supporting documentation
- QS missing on monitored anesthesia care claims
- Physical status modifiers (P1–P6) omitted, cutting base-unit reimbursement
- Anesthesia start and stop times that did not reconcile with the record
What we did
- Audited denied and underpaid claims for modifier accuracy and documentation
- Corrected and resubmitted eligible claims; appealed where payers misapplied rules
- Used No Surprises Act open negotiation and IDR, plus the Texas state dispute process for state-regulated plans
- Set up a pre-bill modifier checklist for the anesthesia team
Results
312 claims reviewed. $487,000 in underpaid and denied revenue identified, $379,000 recovered. Modifier denials fell 64% within 90 days and average turnaround dropped from 94 to 41 days.
Client and physician names are withheld to protect confidentiality.
Correct use of modifier 23 for unusual anesthesia
Cases needing general anesthesia where it is not normally required (patients unable to cooperate, procedures needing extra control) were billed without modifier 23, so payers paid at the routine rate.
What we found
- Modifier 23 left off claims that met the unusual-anesthesia criteria
- Documentation that did not state why anesthesia was medically necessary
- Payers defaulting those claims to standard reimbursement
What we did
- Identified eligible cases and worked with providers to document medical necessity
- Applied modifier 23 with supporting notes and resubmitted
- Appealed underpaid claims with the clinical justification
- Trained the billing team on when modifier 23 applies
Results
186 claims reviewed, 142 corrected and resubmitted. Average payment per corrected claim rose from $412 to $540, and $68,000 in additional revenue was recovered.
Client and physician names are withheld to protect confidentiality.
Recovering underpaid out-of-network claims through Texas Department of Insurance complaints
A Texas out-of-network practice was being paid well below expected amounts by state-regulated plans. Reconsiderations and internal appeals went unanswered or were denied.
What we found
- Payments that did not follow Texas out-of-network rules
- Claims processed late without the required prompt-pay interest
- No written reason given for many payment reductions
What we did
- Identified claims governed by Texas law rather than federal IDR
- Filed complaints with the Texas Department of Insurance with EOBs, appeal history and the relevant rules
- Requested reprocessing with interest and tracked every complaint to closure
Results
203 claims reviewed and 82 complaints filed. $236,000 recovered plus interest, 71% of complaint claims reprocessed, and two payers revised how they process this practice's claims.
Client and physician names are withheld to protect confidentiality.
Raising net collection rate from 88% to 98% for a spine surgeon
An in-network spine practice had a strong case mix but collections trailed contracts. Complex surgical claims were being underpaid, denied or left in A/R.
What we found
- Payments that did not match contracted rates on multi-level procedures
- Instrumentation and add-on codes bundled or reduced
- Prior authorization gaps and documentation that did not support the codes billed
What we did
- Loaded payer contracts and compared every payment line against them
- Appealed underpaid and denied claims with operative notes
- Tightened coding review for spinal fusion, instrumentation and add-on codes before submission
- Put an A/R follow-up cadence on every aged claim
Results
Net collection rate rose from 88% to 98% in six months. $274,000 in underpayments recovered, denial rate down from 15% to 6%, A/R over 90 days down 43%, and days in A/R from 52 to 34.
Client and physician names are withheld to protect confidentiality.
15 minutes. One screen. Your numbers.
A short Google Meet with Rohit to look at where your revenue stalls and whether contingency recovery makes sense for your practice. No software change, nothing to pay up front.