Revenue Cycle Intelligence

We show you exactly why claims are denied and what to do about it

Updated: Today 6:00 AM · 3,300 claims processed
This Month's Finding
UHC Medicare Advantage denies 18.0% of claims — more than double the 8.2% CAH peer average. Prior authorization gaps drive 67% of the issue, concentrated in scheduled surgical procedures. At current overturn rates, $219K is recoverable over the next 90 days through targeted appeals and peer-to-peer reviews.
A/R Aging Snapshot · Total: $9.5M
Days in A/R: 61 · Target: ≤45
0–30 days
$3.1M
33%
31–60 days
$2.5M
26%
61–90 days
$1.5M
16%
91–120 days
$1.1M
12%
120+ days
$1.3M
13%
Cash Posted MTD
$
$4.8M
$400K below target
Target: $5.2M | Days Cash on Hand: 84
Excludes ERC · Methodology ⓘ
Days in A/R
⏱
61
+13 days from January low of 48
Target: ≤45 days | CAH peer median: 50
HFMA MAP Key AR-2 · Methodology ⓘ
Initial Denial Rate
%
11.0%
+2.3% from last month
Target: ≤8% | CAH peer avg: 8.2%
HFMA MAP Key AR-5 · Methodology ⓘ
Write-offs YTD
⊘
$1.6M
$200K better than prior YTD
Prior YTD: $1.8M | 3-yr total: $5.0M
Cash Posting
Cash Posted MTD
By payer category
Medicare $1.9M
Medicaid $1.1M
Commercial $1.4M
Self-Pay / Other $0.4M
Total MTD $4.8M
Cash Posted YTD
By payer category
Medicare $7.2M
Medicaid $4.1M
Commercial $5.3M
Self-Pay / Other $1.4M
Total YTD $18.0M
Denials by Claim Type
Denial Volume by Claim Type
Institutional (837I), Professional (837P), and Other claim forms · Month-to-Date
Claim Type Claims Denied $ Denied % of Total Denied $ Denial Rate
837I (Institutional) 198 $228,400 66% 13.2%
837P (Professional) 148 $96,600 28% 9.1%
Other 17 $20,000 6% 5.4%
Total 363 $345,000 100% 11.0%
Denial Breakdown
Top Denial Root Causes ⓘ
Per HFMA Claim Integrity Task Force taxonomy · Mapped from CARC/RARC codes · Month-to-Date
  • 1
    Front-End · Eligibility
    CARC CO-27, CO-26, CO-31, CO-177 · Owner: Patient Access
    $117,300
    130 claims · 29% of $
  • 2
    Front-End · Authorization
    CARC CO-197, CO-198, CO-199 · Owner: Authorization Team
    $96,600
    88 claims · 24% of $
  • 3
    Coding · Medical Necessity
    CARC CO-50, CO-55, CO-167 · Owner: CDI + Coding
    $62,100
    78 claims · 15% of $
  • 4
    Billing · Missing Info
    CARC CO-16, CO-125, CO-226 · Owner: Billing Team
    $41,400
    44 claims · 10% of $
  • 5
    Timely Filing
    CARC CO-29, CO-109 · Owner: Billing Team
    $27,600
    23 claims · 7% of $
Denial Distribution
By revenue cycle stage
$345K
Total Denied
Front-End (62%) · $214K Middle (18%) · $62K Back-End (20%) · $69K
AI-Powered Insights
AI Analysis
What's Driving Your Denial Rate
Plain English insights, not just codes
Payer Driverⓘ
UHC MA drives 36% of monthly denied dollars at 18.0%
Out of $345K denied this month, $125K comes from UHC Medicare Advantage alone. The 18.0% denial rate runs 9.8 points above the 8.2% CAH peer average. Prior auth is 67% of the UHC MA issue.
$219K recoverable (90-day)
Root Cause Driverⓘ
Eligibility failures are the largest denial bucket at $117K/month
130 claims denied for eligibility reasons, 34% of all denied dollars. Commercial Payer B runs 51% eligibility as its top issue. One process, touching multiple payers, owns a third of the total.
$117K/month · 130 claims
Function Driverⓘ
Front-end ownership accounts for 62% of monthly denials
Patient Access owns 34% (eligibility) and the Authorization Team owns 28%. Combined, $214K of the $345K denied originates before the claim leaves the building. Coding and billing together own the remaining 38%.
$214K/month · 62% of denials

Revenue Pulse

Daily Management Board · Lead measures drive lag outcomes

Test data · Refreshes hourly in production
1 On Target
4 At Risk
3 Critical
Daily Huddle: 8:30 AM RCM Team · Conference Room B
Q2
Goal
Denial Rate 11.0% → 8.0%
Day 14 of 90 $68K / $420K
Behind pace 1.2 pts
Lead Measures · What We Control
Eligibility Verified Same-Day
At Risk
78%
Target
≥95%
7 days ago Today ↑
Auth Obtained Before Service
At Risk
84%
Target
≥98%
7 days ago Today →
POS Collections Rate
Critical
22%
Target
≥40%
7 days ago Today ↑
Clean Claim Rate (First Pass)
On Target
94%
Target
≥95%
7 days ago Today ↑
Lag Measures · What We Get
Denial Rate
Critical
11.0%
Target
≤8%
7 days ago Today ↑
Days in A/R
Critical
61
Target
≤45
3 months ago Today ↑
Cash Posted MTD
At Risk
$4.8M
Target
$5.2M
7 days ago Today →
Recovery Rate
At Risk
52%
Target
≥65%
7 days ago Today ↑
Today's Win
Clean Claim Rate hit 94% yesterday, best week since January
Dr. Bennett's team
Calls to Action
Today's Priorities 3
Owned · On Deck for Huddle
1
UHC MA prior auth: 67% of denials · $125K MTD at 18.0% vs 8.2% peer
Owner
Auth Team Lead
2
47 BCBS claims expiring in 14 days · $46K expected ($89K gross at 52% overturn)
Owner
A/R Supervisor
3
POS collections stuck at 22% · Estimate-at-registration pilot starts this week
Owner
Patient Access Mgr

Payer Intelligence

Track payer behavior changes and denial patterns by payer

Highest Denial Payer
!
UnitedHealthcare MA
18.0% denial rate
Best Performing
✓
Medicare FFS
4.0% denial rate
Slowest to Pay
⏱
Commercial Payer B
55 days average
Payers Analyzed
#
12
3,300 claims/month
Payer Performance Matrix ⓘ
Per HFMA MAP Key AR-5 · Claim-level denial rate · Month-to-Date
Payer Claims Denial Rate $ Denied Avg Days to Pay Trend Top Issue
UnitedHealthcare MA
750 18.0% $125K 38 ↑ 2.1% Prior Auth (67%)
Commercial Payer B
480 14.6% $65K 55 ↑ 1.8% Eligibility (51%)
Blue Cross Blue Shield
620 10.3% $59K 35 ↓ 1.2% Coding (42%)
Medicare FFS
870 4.0% $32K 28 → 0.3% Info Missing (22%)
AI Analysis
Payer-Specific Recommendations
Based on pattern analysis of your denial data
UnitedHealthcare
UHC MA denial rate is more than double the peer benchmark
18.0% denial rate versus 8.2% CAH peer average. Prior auth drives 67% of the UHC MA issue. 90-day denied inventory is $365K. At the standard 60% recovery rate, $219K is recoverable.
Commercial Payer B
Eligibility is 51% of denials and slowest to pay at 55 days
$188K denied over 90 days at 13.9% rate. Average 55 days to pay, the slowest payer on the panel. Eligibility verification timing is the pattern: checks performed days before service are expiring at registration.
BCBS
BCBS is the only payer trending better month over month
10.3% denial rate, down 1.2% month over month. Coding is 42% of BCBS denials, meaning the improvement is coming from coding work. The playbook from BCBS is portable to UHC MA and Commercial B.

Provider Intelligence

Denials, productivity, and documentation quality by provider

Highest Denial Provider
!
Dr. Edwards
15.4% · General Surgery
Most Productive
✓
Dr. Anderson
104% of wRVU target
Attention Needed
⚠
3
Providers with denial rate > 12%
Provider Performance Matrix (Top 10)
Sorted by denial rate, highest to lowest · Click any row to see denial breakdown, top CARC codes, and coaching opportunities
Provider Specialty Claims Denial Rate $ Denied wRVU (% of Target) Query Response Top Issue
Dr. Edwards
General Surgery 182 15.4% $47K 98% 3.2 days Prior Auth (62%)
Dr. Anderson
Orthopedic Surgery 214 13.1% $41K 104% 4.8 days Documentation (48%)
Dr. Chen
Emergency Medicine 486 12.7% $38K 92% 1.4 days Eligibility (57%)
Dr. Davis
Urology 168 11.8% $24K 96% 2.1 days Coding (44%)
Dr. Foster
ENT 142 10.2% $18K 89% 2.6 days Prior Auth (38%)
Dr. Harris
Cardiology 208 9.6% $22K 87% 1.9 days Documentation (41%)
Dr. Bennett
Family Medicine 392 8.1% $15K 101% 0.9 days Info Missing (33%)
Dr. Greene
Family Medicine 348 7.8% $12K 97% 1.1 days Info Missing (29%)
AI Analysis
Provider-Specific Recommendations
Coaching opportunities and productivity insights
Dr. Edwards · Gen Surgery
62% of denials are prior auth related
Pattern suggests pre-cert workflow gap on scheduled procedures: auth captured for the primary procedure but not for bundled imaging and pre-op services. $47K denied MTD, $29K attributed to prior auth, $17K expected recovery at 60% standard rate.
$29K prior auth denied · $17K expected
Dr. Anderson · Orthopedic Surgery
Productive at 104% wRVU, but slowest query response on the medical staff
4.8-day query response versus a medical-staff range of 0.9 to 3.2 days for all other providers. Documentation is 48% of his denial category. Query responsiveness is a direct lever on DNFB; a mobile query workflow would compress turnaround.
4.8 days · 214 claims · $41K denied
Family Medicine Team
Dr. Bennett and Dr. Greene are the template
Both running under 8.5% denial rate with sub-1.5 day query response. Their intake workflow is the cleanest on the medical staff. Worth sharing the playbook with the specialty clinics and ER team.
Best practice pattern

Recovery Opportunities

Prioritized by deadline, dollar value, and likelihood of success

Money on the Table
$950K
Denied in Last 90 Days
$570K
Recoverable
Based on historical overturn rates by denial category and payer
$120K
At Risk (Deadline Soon)
A/R Aging Analysis
$3.1M
0-30
$2.5M
31-60
$1.5M
61-90
$1.1M
91-120
$1.3M
120+
Prioritized Recovery Actions
AI-ranked by dollar value, deadline proximity, and historical success rate
  • !
    47 claims expiring in 14 days
    Missing secondary EOB · Payer: BCBS · Appeal window closes Apr 28 · 52% historical overturn rate
    $89K
  • 2
    38 claims with auth on file but not submitted
    Prior Auth documentation exists · Payer: UHC · Quick resubmit opportunity
    $67K
  • 3
    23 claims with fixable modifier issues
    AI identified correctable coding errors · High overturn rate expected
    $54K
Preview · Coming Q3 2026
Appeals Workflow module is in design. This preview shows what the live view will look like using illustrative data.

Appeals Workflow

Appeal queue, peer-to-peer tracking, overturn intelligence, AI-assisted letter generation

Active Appeals
47
$186K
At Stake
12
Urgent (≤7 days)
Overturn Rate YTD
✓
58%
HFMA benchmark: 54%
Avg Days to File
⏱
12
Target: ≤7 days
Peer-to-Peer Queue
#
9
Scheduled this week
Appeal Worklist · Prioritized by Deadline
47 open appeals · sorted by days to filing deadline · click any row for clinical detail and AI-drafted letter
Priority Claim Payer Physician Denial Reason Date of Denial Amount Days to Deadline Status
URGENT CL-44219
Inpatient DRG 291		 UHC Medicare Advantage Dr. Bennett Medical necessity (CO-50) Mar 28 $8,420 3 days Draft Pending
URGENT CL-44187
CT with contrast		 UHC Medicare Advantage Dr. Edwards Prior auth required (CO-197) Mar 25 $3,215 5 days Letter Ready
HIGH CL-44156
Swing bed day 6		 BCBS Commercial Dr. Harris Level of care (CO-B5) Mar 21 $12,680 9 days Peer-to-Peer
HIGH CL-44102
ED observation		 BCBS Commercial Dr. Chen Two-midnight rule (CO-B5) Mar 18 $5,890 11 days Draft Pending
STD CL-44078
Lab panel		 Commercial Payer B Dr. Davis Missing documentation (CO-16) Mar 12 $1,240 18 days Submitted
STD CL-44034
Physical therapy		 Medicare FFS Dr. Foster Frequency limit (CO-151) Mar 8 $860 22 days Submitted
+ 41 additional appeals in queue · view all
Overturn Rate by Payer
Where your appeals win · last 90 days
Medicare FFS 74%
26 of 35 appealed · $42K recovered
BCBS Commercial 62%
18 of 29 appealed · $68K recovered
UHC Medicare Advantage 48%
22 of 46 appealed · $94K recovered · peer-to-peer critical
Commercial Payer B 41%
9 of 22 appealed · $17K recovered
Insight: UHC MA has the lowest overturn rate but the highest dollar recovery opportunity. Peer-to-peer reviews overturn 71% of UHC MA denials versus 34% for written appeals. The data supports moving UHC appeals to peer-to-peer first.
Peer-to-Peer Review Queue
9 reviews scheduled this week · physician prep required
Physician Payer Diagnosis Scheduled
Dr. Bennett UHC MA Sepsis (A41.9) Tomorrow 2pm
Dr. Chen BCBS Pneumonia (J18.9) Wed 10am
Dr. Bennett UHC MA CHF exacerbation (I50.9) Wed 3pm
Dr. Harris Commercial B Swing bed (Z51.5) Thu 9am
Dr. Edwards UHC MA Observation obs (Z03.6) Thu 1pm
Dr. Greene BCBS COPD (J44.1) Fri 11am
AI-Assisted Appeal Letter · CL-44187 · UHC Medicare Advantage
Drafted in 8 seconds from the clinical documentation. Review, edit, and submit.
AI Draft
Letter Preview

Re: Member ID 8842XXXXX · Claim CL-44187 · Date of Service March 14, 2026

To the UnitedHealthcare Medical Review Team,

Schoolcraft Memorial Hospital submits this formal appeal of the denial issued under CARC CO-197 (prior authorization required) for the CT scan with contrast performed on the above-referenced date of service. We respectfully request reconsideration based on the clinical circumstances documented below.

The patient presented to our Emergency Department on March 14 at 14:22 with acute abdominal pain rated 9 of 10, fever of 101.4F, and a 24-hour history of worsening right lower quadrant tenderness. Per the attending physician's documentation, emergent imaging was clinically indicated to rule out acute appendicitis and bowel obstruction. Under UnitedHealthcare's own medical policy (reference MCG 24th edition, Acute Abdominal Pain), emergent imaging in the ED setting is exempt from standard prior authorization requirements when clinical presentation meets acute care criteria...

[continues for 3 more paragraphs with clinical citations and supporting documentation]

Methodology & Definitions

Every number on this dashboard, explained · Every rule documented · Every source traceable

Version 1.0 · April 2026
Why this page exists. Revenue Cycle leaders and CFOs should never have to guess where a number came from. This page documents the definition, equation, data source, time window, and industry anchor for every metric on this dashboard. Calculations follow HFMA MAP Keys and the HFMA Claim Integrity Task Force denial taxonomy where applicable. When your engagement moves from prototype to live data during the Assess sprint, every illustrative value on the other tabs is replaced with a calculated value traceable to this page.
KPI Definitions AI Insight Rules Denial Categorization Pulse RAG Thresholds Data Sources & Refresh Data Integrity Notes Roadmap
1. KPI Definitions
Every headline metric · HFMA MAP Keys anchor where applicable
Metric HFMA Anchor Equation Time Window Data Source
Denial Rate MAP Key AR-5 (Remittance Denial Rate) Denied claims ÷ Total claims remitted · at claim level, not line level Month-to-Date 835 ERA + claim submission log
Days in A/R MAP Key AR-2 (A/R Days) Net A/R ÷ (Net patient service revenue ÷ days in period) Rolling 3-month Patient accounting system + GL
Cash Posted MTD Operating metric (not MAP Key) Sum of payment transactions posted to patient accounts · Excludes ERC, one-time federal payments Month-to-Date Patient accounting system
Initial Denial Rate HFMA Claim Integrity Task Force Metric 1 Claims denied on first submission ÷ Total claims submitted · reported by both volume and $ Month-to-Date 835 ERA + 837 submission log
Recovery Rate HFMA Claim Integrity Task Force Metric 4 (Overturn %) $ recovered through appeals/resubmissions/corrections ÷ $ originally denied Rolling 90-day 835 ERA secondary remits
Clean Claim Rate (First Pass) Operating metric (industry standard) Claims accepted on first submission without edit or rework ÷ Total claims submitted Rolling 7-day Clearinghouse rejection log + 835 ERA
Eligibility Verified Same-Day Operating metric · MAP Key PA-3 adjacent Registrations with eligibility confirmed on DOS ÷ Total registrations Rolling 7-day Eligibility transaction log (270/271)
Auth Obtained Before Service Operating metric · MAP Key PA-6 adjacent Scheduled procedures with auth on file ≥24 hours pre-service ÷ Total procedures requiring auth Rolling 7-day Authorization tracking log
POS Collections Rate MAP Key PA-7 adjacent $ collected at/before service ÷ $ estimated patient responsibility Rolling 7-day Patient accounting POS module
Overturn Rate by Payer HFMA Claim Integrity Task Force Metric 4 Appeals won ÷ Appeals filed · grouped by payer Rolling 90-day Appeal tracking system + 835 ERA
2. AI Insight Classification Rules
How findings are ranked and labeled · Every rule documented, not heuristic
Critical Finding
Triggered when one of: dollar impact ≥ $100K over prior 30 days · trending worse for 14+ consecutive days · filing or compliance deadline inside 14 days · payer rule change detected without operational response.
Deadline Approaching
Claims or appeals with filing deadline inside 30 days AND recoverable amount ≥ $25K. Triggered by appeal filing window, timely filing limit, or resubmission window.
Quick Win
Process change with recurring monthly $ impact AND implementation effort estimated at under 30 days. Excludes findings requiring payer renegotiation or system replacement.
Hidden Leak
Reported metric masks larger exposure due to workflow gap. Triggered when metric A is low but metric B (upstream or related) is materially higher. Example: self-pay % low, but denied claims never billed to patients is high.
Note on revenue cycle stage grouping. Front-End combines Eligibility (Patient Access) and Authorization (Auth Team) because both occur before the claim leaves the building. Middle covers CDI and Coding (medical necessity). Back-End covers Billing (missing info) and Timely Filing. Dollar totals are derived from the CARC-mapped root cause list and cross-validated against the owner-function breakdown.
3. Denial Categorization Matrix
CARC/RARC codes mapped to HFMA Claim Integrity Task Force categories
Category CARC Codes Owner Function Typical Resolution
Front-End · Eligibility CO-27, CO-26, CO-31, CO-177 Patient Access Verify coverage, rebill correct payer
Front-End · Authorization CO-197, CO-198, CO-199 Authorization Team Retro-auth request, peer-to-peer, appeal
Coding · Medical Necessity CO-50, CO-55, CO-167 CDI + Coding Clinical documentation appeal
Coding · Level of Care CO-B5, CO-B7 UR + Physician Advisor Peer-to-peer review, two-midnight defense
Billing · Missing Info CO-16, CO-125, CO-226 Billing Team Resubmit with missing data
Billing · Duplicate CO-18 Billing Team Investigate, void one submission
Contractual CO-45, CO-131 Finance / Contract Mgmt Not actionable · write-off per contract
Timely Filing CO-29, CO-109 Billing Team Proof-of-timely-filing appeal if applicable
4. Revenue Pulse RAG Thresholds
When does each metric go green, yellow, or red · Thresholds set in collaboration with hospital leadership
Metric On Target At Risk Critical
Denial Rate≤ 8%8% to 10%> 10%
Days in A/R≤ 4546 to 55> 55
Cash Posted MTD vs TargetWithin 5%5% to 12% under> 12% under
Recovery Rate≥ 65%50% to 64%< 50%
Clean Claim Rate (First Pass)≥ 95%90% to 94%< 90%
Eligibility Verified Same-Day≥ 95%80% to 94%< 80%
Auth Obtained Before Service≥ 98%90% to 97%< 90%
POS Collections Rate≥ 40%25% to 39%< 25%
5. Data Sources & Refresh Cadence
Where each feed comes from, how often it updates, and what happens when a source is unavailable
Source Feeds Cadence Fallback if Unavailable
Patient Accounting (Oracle Health Community Works)A/R, Cash Posted, Patient DemographicsNightly batchDisplay last-known with timestamp; flag amber
835 ERA (clearinghouse feed)Denials, Payments, Recovery RateReal-time as receivedQueue for next refresh; no stale display
837 Claim Submission LogClaim volume, Clean Claim RateReal-time as submittedQueue and backfill
Eligibility Transactions (270/271)Eligibility Verified Same-DayReal-timeQueue and backfill
Authorization Tracking LogAuth Obtained Before ServiceHourlyDisplay last-known with timestamp
Appeal Management SystemOverturn Rate by Payer, Appeal QueueDailyLast-known with timestamp
6. Data Integrity Notes
How we handle the three questions every RCM analyst asks first
Denial code prioritization: weighted, not last-posted
When a CPT line has multiple CARC codes posted across remits, we apply a weighted methodology that prioritizes the highest-impact denial reason rather than the last code posted. Last-code-posted methodology systematically undercounts upstream issues (eligibility, auth) when downstream posting overwrites with contractual or admin codes. Weighting rules are configurable per hospital during Assess.
Denial reconciliation to A/R: claim-level, not line-level
Denial totals are counted at claim level per HFMA AR-5. Services with multiple denied CPT lines on the same claim are not double-counted in headline denial rate. A separate line-level view is available on the Top Denial Root Causes page for operational drill-down, clearly labeled as "line count" to avoid confusion with claim-level headlines. Reconciliation to billed A/R is performed nightly against the patient accounting total.
Bill type separation: UB (837I) vs 1500 (837P) vs Other
Institutional (UB/837I), professional (1500/837P), and other (invoice/misc) claim types have materially different denial patterns and resolution workflows. The Top Denial Root Causes filter supports drill-down by bill type. Headline denial rate can be viewed in aggregate or segmented. Rural Health Clinic and Critical Access specific rules are applied where applicable.
Cash Posted excludes one-time federal payments
ERC, Provider Relief Fund, and similar one-time payments are excluded from Cash Posted MTD to preserve operational accuracy. Net position and balance sheet views include these amounts with separate line identification.
7. Roadmap · What's MVP, What's Phase 2, What's Phase 3
Feedback from Revenue Cycle leaders shapes what ships when
MVP · Live
  • ✓ Executive Summary
  • ✓ Revenue Pulse daily board
  • ✓ Payer Intelligence
  • ✓ Provider Intelligence
  • ✓ Recovery Opportunities
  • ✓ Denial Root Cause by CARC/RARC
  • ✓ 835 ERA integration
  • ✓ Time window filters (MTD / 90d / YTD)
Phase 2 · Q3 2026
  • → Appeals Workflow
  • → Predictive Denial Prevention
  • → Unapplied Cash view
  • → Unidentified Payments tracking
  • → Recoupment tracking
  • → Bill type drill-down (UB/1500/Other)
  • → Payer sub-category breakdown
  • → Peer-to-peer review queue
Phase 3 · Q4 2026 +
  • → Admission Source analytics (volume & cash)
  • → Transfer tracking (volume, cash, reason)
  • → Strategic partnership rationale engine
  • → Contract Pulse (silent underpayment detection)
  • → AI-assisted appeal letter generation
  • → Multi-facility roll-up view
  • → Board-ready export templates
  • → HFMA MAP Award readiness scorecard
Your feedback shapes this roadmap. Phase 2 and Phase 3 priorities are informed by discovery conversations with hospital leadership. Items that matter most to your operation get prioritized.
🔮

Predictive Denial Prevention

AI-powered claim scoring before submission. Coming Q3 2026 after we've learned from your denial patterns.

What's Coming:
  • Real-time claim risk scoring (0-100) before submission: Avg risk score: 45
  • Auto-fix suggestions for common issues: 22% of flagged claims auto-corrected
  • Eligibility verification at scheduling: 83% verified pre-service
  • Payer-specific rule engine updates: 30 rule updates active
  • Prevention success tracking and ROI measurement: $65K estimated monthly denial prevention

We're building this carefully using your actual denial data, not generic models.
The foundation we're laying now makes this possible.