Payment integrity audits
Reconciling paid amounts against contracts, rate schedules, and program rules. Underpayments to recover on the commercial side. Improper payments and duplicate disbursements to reclaim on the government side.
Payer data, denial benchmarks, and operational insights for billing companies and healthcare organizations. Real numbers, cited sources, honest reads.
Every finding in a revenue-integrity audit is either money to recover or an exposure to close. Usually both. Each category below collects the writing, the benchmarks, and the tools we have for it.
Reconciling paid amounts against contracts, rate schedules, and program rules. Underpayments to recover on the commercial side. Improper payments and duplicate disbursements to reclaim on the government side.
Automated identification, root-cause classification, and drafting of the appeal or dispute. Denials never worked, aged AR about to expire, unrecovered clawbacks. Human review before anything goes out.
Services delivered but never billed. Costs incurred but never recovered. The cross-check between clinical or operational documentation and the invoices, claims, or reimbursements actually filed.
RAC, TPE, SMRC, OIG, and GAO audits are up in both volume and dollar recovery targets. Response packets, documentation gap-closing, ongoing exposure monitoring, and clawback prevention.
Payers change rates. Vendors change terms. Program rules shift. Ongoing monitoring that surfaces silent contract changes, fee-schedule drift, and carve-out misapplications before 60 days of underpaid transactions ship.
The same numbers land differently depending on whether you sign payroll at a billing company, run revenue cycle at a hospital, sell DME under CERT scrutiny, or run payment integrity inside a federal program. Pick your seat.
Denial management, aged AR, EOB automation, staffing turnover, AI substitution math. Written for the person who signs payroll at the RCM shop.
Contract underpayment recovery, missed charge capture, coding accuracy, ongoing payer-contract monitoring. Enterprise RCM at 100 to 5,000 bed hospitals and integrated delivery systems.
LCD compliance, prior authorization, KX modifier discipline, CERT audit risk at 24 percent DMEPOS improper rate. Home health, hospice, DME, PT, ABA.
Improper payments, fraud waste and abuse, Medicaid compliance, CERT and OIG audit response. For payment-integrity leads inside federal and state agencies, not the vendors selling to them.
The published pieces are live now. The "coming soon" pieces are scoped, sourced, and being written. If one of them is what you needed today, book a call and I will send the draft.
RCM services buyer's guide. Full-BPO, extended business office, specialty services, hybrid AI models. Pricing, contract terms, and the decision framework.
What CAC, autonomous coding, and AI-augmented review actually automate, where certified coders still earn their keep, and the 8-item buyer's checklist.
Every step of the healthcare revenue cycle end-to-end: patient access through zero-balance, who owns what, what breaks, and how to measure it.
Both spellings are correct. Which one to use when, what it actually means in claims and contracts, and how the term shows up in payer-mix analysis and payer relations.
HFMA and AAHAM certifications explained. What each cert covers, what it pays, prep time, cost, renewal, and how to choose your first credential.
CO-16, CO-45, CO-50, CO-197 explained with what triggers each, how to fix it, and how to appeal. The four denial codes that eat most of your recoverable pool.
Category map, feature checklist, pricing benchmarks, and how to tell whether you need a platform, a service, or a custom AI biller.
What the 835 remittance actually contains, what auto-posts cleanly, where the exceptions live, and the workflow that frees 1.5-2.5 billers at 5,000 claims/month.
Real-time vs batch, coverage discovery, common failure modes, and the four-step workflow that catches problems the night before the visit.
What CDI specialists actually do day to day, when to hire your first one, the software category map, and where AI multiplies specialist throughput 3-5x.
Workflow-by-workflow breakdown of where AI is changing RCM economics, where it is still oversold, and how to think about build-vs-buy for a 5 to 500 FTE billing operation. Turnover math, denial recovery math, 90-day rollout template.
Industry-wide less than 1% of denied claims are ever appealed, and 44% of those are overturned. Workflow-by-workflow guide to recovering the appealable pool your team currently writes off.
Silent rate changes, fee-schedule drift, and carve-out misapplications quietly cost hospitals and medical groups two to five percent of every commercial claim. How to detect it, how to recover it.
GAO measures $233 billion in improper federal payments every year. Written for the program managers and payment-integrity leads inside CMS, VA, DoD, and state Medicaid. Not for the vendors selling to them.
Part B improper payment rate is 8.44 percent. DMEPOS is 24.12 percent. What each audit is, what the ADR demands, and the workflow that turns clawback threats into zero findings.
Services documented in the chart or the ops log but never actually billed. The cross-check between clinical documentation and the claims file that surfaces the 3-8% pool.
Category map, CMS-0057-F rule changes, and the four-step workflow that catches expiring authorizations before the visit denies. Written for specialty practices with a heavy auth footprint.
What a biller actually costs in 2026. Base pay, ramp deficit, aged AR expired during vacancies, and the AI substitution math. Written for RCM company owners and provider administrators sizing headcount.
Days in AR, clean claim rate, net collection rate, cost to collect, and the six other metrics that separate a healthy billing operation from one leaking cash. Includes an interactive scorecard.
The revenue-leakage workflows above are not consulting slides. They are software. Here is the specific AI stack each one runs on, with a link to the deep-dive on each capability.
Longer catalogue for anyone who wants the technical architecture behind the stack. Also includes 30+ vertical deep-dives from earlier writing (cities, government agencies, medical practices, behavioral health, dental, legal).
Pick your state and specialty. See the payer denial leaderboard, appeal-recovery ceiling, filing deadlines, and locality-adjusted reimbursement for your top codes. Every figure sourced from public data. Four minutes.