What we deliver
Two deliverables.
One analyst.
The Claim Risk Predictor scores claims before submission. The Pattern Report surfaces structural denial intelligence from adjudicated history. Your team uploads files. Prexisio handles the rest.
A scored work order for the billing team before every submission run.
Prexisio analyzes your adjudicated claims history, then scores every claim in your pre-submission batch against the patterns it found. The billing team receives a prioritized work order with every claim ranked by risk and every HIGH risk claim annotated with the specific action required before submitting.
What the practice receives
The billing team works a list, not a judgment call. CERTAIN denials are blocked. HIGH risk claims have named interventions, with prior authorization requests and appeal letters drafted for analyst review when correspondence is the fix. LOW risk claims submit without modification.
Pre-Check Layer
Will this claim be automatically denied before scoring?
Timely filing violations, deleted ICD-10 codes, and other regulatory hard blocks are caught before the ML model runs. These claims are CERTAIN DENIALS — do not submit until corrected.
Graph Pattern Scoring
How likely is this claim to deny, based on this practice's history?
A pattern model trained on your adjudicated claims scores each pre-submission claim. Payer, CPT code, ICD code, modifier, RVU, and provider are all factors. The model learns from your specific history, not industry averages.
Prioritized Work Order
What should the billing team do with each flagged claim?
The work order is sorted by urgency: CERTAIN DENIAL first, HIGH risk by dollar amount, MEDIUM, LOW. Each HIGH risk claim includes a specific required action — the exact intervention needed before submitting.
Structural denial intelligence for the billing director and practice administrator.
From 12 months of adjudicated claims, Prexisio surfaces the structural patterns driving denials across payers, procedures, and diagnosis codes. The Pattern Report names the specific combinations — Aetna PPO and CPT 64483 at 42%, UHC and CPT 64635 at 35% — so leadership acts on data, not intuition.
What the practice receives
The billing director receives a named, specific intelligence report — not generic benchmarks. The four recommended actions (Eliminate, Reduce, Raise, Create) each reference a specific named payer or procedure.
Denial Driver Analysis
Which payer-procedure combinations are driving the most denials?
The top denial drivers are ranked by impact — denial rate, dollar exposure, and force type (authorization, coding, medical necessity, eligibility). Each driver is named with a specific payer and CPT code.
Underpayment Detection
Which payers are paying below the contracted rate on paid claims?
Prexisio computes the payment ratio per payer from actual paid claims and compares it against the expected rate for the plan type. Payers paying more than seven points below expected are flagged for contract audit.
Recommended Actions
What should leadership do first?
Four specific actions: what to Eliminate (highest-dollar denial driver), what to Reduce (second driver), which payer relationship to Raise (largest underpayment gap), and what new workflow to Create. Each references a named payer or procedure.
See both deliverables in action for your practice.
The pattern model is trained on your adjudicated claims history. The scoring is specific to your payer mix, procedure mix, and denial patterns.
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