Where this started
In 2019, a multi-site pain management organization in Tampa, Florida asked for help understanding their denial rates and revenue integrity. Standard reports showed claims were being paid. What they did not show was whether those claims were being paid correctly.
Comparing contracted allowed amounts against actual payments revealed a systematic underpayment gap across multiple payers — revenue that had been earned, billed, and technically paid, but at rates the contracts did not support.
The same engagement surfaced the denial patterns. The same payer-procedure combinations were denying cycle after cycle. Nobody could see them before submission because no layer existed between the billing system and the payer.
That same gap — the one between submitting and knowing — became the foundation for Prexisio: a managed service that scores claims before submission and delivers the structural pattern intelligence that prevents the denial from repeating.
$2M+
Underpayment gap identified inside paid claims at one practice
28%
Overall denial rate at engagement start vs 15% industry benchmark
4
Payer-procedure combinations identified as primary denial drivers
The pattern we kept seeing
The denial was visible before submission
The data to predict a denial existed before the claim left the billing system. The payer, the procedure code, and the diagnosis code together told a story that only became visible after the denial came back — weeks later.
The underpayment was hiding inside paid claims
Claims were being paid. Nobody had compared what was paid against what the contracts required. The gap between those two numbers was material — and it had been accumulating for years.
The pattern was repeating because nobody could see it
The same payer-procedure combinations were denying cycle after cycle. Standard reporting showed denial volume. It did not show which specific combinations to fix first or what to do before submitting.
The same intelligence gap in GI
A PE-backed GI management services organization had acquired multiple practices. Each had its own payer mix and billing history. Leadership could see denial rates inside each practice. They could not see the denial patterns across the organization or which payer-procedure combinations were denying at disproportionate rates portfolio-wide.
The gap we exist to fill
Practices already have RCM vendors, billing tools, and EHR reports. None of them score what is about to be submitted.
RCM vendors
RCM vendors work denials after adjudication. By the time the denial comes back, the timely filing window has narrowed and the billing team has moved on to the next batch. Leadership still does not know which claims in the next batch are likely to deny.
Denial management tools
Denial management tools organize what has already denied. They do not score what is about to be submitted. The gap is upstream — before the claim reaches the payer, not after it comes back.
EHR and billing reports
Standard reports show what happened inside one system. Denial patterns emerge across the intersection of payer, procedure, diagnosis code, and provider — across the entire adjudicated history. That view does not exist inside a single system.
What we believe
Denials are not random. The payer, the procedure, the diagnosis code, and the history of how that combination has been adjudicated all point to what is likely to happen before the claim ever leaves the billing system.
The question is not whether the intelligence exists. It is whether anyone is using it before submission — or waiting to find out after.
Prexisio exists to use it before.
The principles we operate by
Pre-submission beats post-denial
A denial caught before submission is a denial that never happened. The claims data contains the pattern. Prexisio surfaces it before the claim leaves the billing system.
Client-specific beats generic
A 42% denial rate for Aetna PPO on CPT 64483 at this practice is more useful than an industry benchmark. The intelligence has to come from the practice's own claims history, not population averages.
Specific actions beat reports
The value is not a dashboard or a denial rate chart. It is knowing which claims to pull back before submitting and which contract to audit first. Named, specific, and actionable.
Delivery should not create more work
The billing team receives a scored work order. The billing director receives a Pattern Report. The practice uploads one file. Prexisio handles the rest.
What we will not do
- Name a specific denial rate or underpayment before seeing the practice's actual claims history
- Present industry-average benchmarks as client-specific revenue intelligence
- Ask the practice to manage another dashboard or software system to receive value
- Guarantee that specific claims will be paid after intervention
Who this is for
Specialty practices and health system service lines where denial patterns are specific to procedure codes, payer behavior, and authorization requirements. The model trains on your claims history, not a specialty template, so the engagement fits wherever procedural claim volume is high.
Specialty practices with high procedural claim volume
Authorization requirements, payer-specific bundling rules, and procedure-level denial patterns create the conditions where pre-submission scoring delivers the most value.
Billing directors who need named patterns, not categories
The Pattern Report names the specific payers and procedure codes driving denials — not generic denial category summaries. Leadership acts on specifics, not aggregates.
How it works
One analyst. Two deliverables. The practice uploads files. Prexisio handles the analysis and delivery.
Step 1
Share your claims history
The practice provides 12 months of adjudicated claims — what was billed, allowed, paid, and why claims denied. Prexisio analyzes the history and builds the denial intelligence from your practice's own data.
Step 2
Receive the scored work order
Before each submission run, the billing team uploads the pre-submission batch. Prexisio scores every claim and returns a prioritized work order — CERTAIN denials blocked, HIGH risk claims annotated with specific required actions.
Step 3
Receive the Pattern Report
Monthly, the billing director and practice administrator receive a Pattern Report naming the structural denial drivers, flagging payers paying below contract, and delivering four specific recommended actions.
See the Claim Risk Predictor scored on your next submission batch.One file. Prexisio handles the rest.
Share 12 months of adjudicated claims. Prexisio builds the denial intelligence from your practice's own history and returns a scored work order for your next submission cycle.