Gastroenterology
Score every endoscopic claim before it denies.
Gastroenterology practices face denial pressure on colonoscopy, EGD, and procedural codes from commercial payers with varying medical necessity and authorization standards. The same payer-CPT patterns deny cycle after cycle because the billing team has no visibility into which claims are at risk before submission.
Request a DemoWhat Prexisio surfaces for pain management practices.
The Claim Risk Predictor catches issues before submission. The Pattern Report surfaces the structural patterns after adjudication.
Authorization failures on GI procedural claims
Commercial payers often require prior authorization for high-volume endoscopic procedures. The Claim Risk Predictor flags claims missing authorization before submission so the billing team can obtain approval before the claim leaves the system.
Diagnosis code specificity and currency
Deleted or unspecified ICD-10 codes trigger automatic CO-11 denials. Prexisio's pre-check layer catches these before any ML scoring occurs, blocking the claim from submission and requiring correction.
Timely filing violations
Claims submitted after the payer's timely filing window receive CO-29 denials with no appeal path. Prexisio flags these as CERTAIN DENIALS before submission so the billing team never sends an unrecoverable claim.
Payer-procedure denial patterns
The Pattern Report names the specific payer-CPT combinations driving the highest denial rates in this practice's history. Colonoscopy, EGD, and procedural claim denial rates by payer — named specifically, not described generically.
Underpayment on paid interventional claims
A payer accepting the claim is not the same as a payer paying the contracted rate. Prexisio detects payers where the actual payment ratio is more than seven points below the expected rate for the plan type and flags them for contract audit.
Multi-site and multi-payer visibility
Pain management practices often operate across clinic and ASC settings with different payer mixes at each site. The Pattern Report surfaces denial and underpayment patterns across all sites, providers, and payers in the adjudicated history.
The questions Prexisio answers for your practice.
Claim Risk Predictor
- Which claims in this batch are likely to be denied by Aetna, UHC, or Medicare?
- Which claims carry deleted ICD codes or timely filing violations?
- Which endoscopic CPT codes are missing authorization for specific payers?
- What does the billing team need to do for each HIGH risk claim before submitting?
Pattern Report
- Which payer-CPT combinations are denying at the highest rates in this practice?
- Which payers are paying below the contracted rate on paid interventional claims?
- What are the four most important revenue actions for the billing director this period?
- Where is the denial rate above the 15% industry benchmark and why?
What Prexisio needs from your practice.
Adjudicated Claims History
12 months of paid and denied claims with CPT, ICD, modifier, payer, billed, allowed, paid, and denial reason
Pre-Submission Batch
The claims file the billing team is preparing to submit — exported from the practice management system
No EHR integration. No dashboard adoption. The analyst uploads the files and returns the scored work order and Pattern Report.
See the Claim Risk Predictor scored on your GI pre-submission batch.
Share 12 months of adjudicated claims. Prexisio trains the pattern model and returns a scored work order for your next submission cycle.
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