§A win rate only counts the disputes somebody filed
One hundred eligible disputes, one quarter, one location. File the easy two thirds, drop the rest, and you have bought yourself a 97%.
Thirty-five eligible disputes were never worked.
Seven losses on the record, taken on purpose. Batching and the $15 administrative fee make the marginal thirty-five worth filing.
Four points worse on the win-rate, and $55,600 more in the account. Knowing how to run an open negotiation is what makes the cash flow.
The leak that never appears in a denial report
No denial. No queue. No flag.
the code you billed is still in the file
Without the sixth field this line is a level 3 paid under charges, which is unremarkable. With it, the file states that you billed a level 5.
Blue Cross Blue Shield of Texas turned on new ClaimsXten editing in July 2026, two rules specific to emergency claims. From 1 July its E/M editing pays the lower level of service it validates.
UnitedHealthcare routes emergency claims through the Optum EDC Analyzer, which scores the visit from the presenting problem, the diagnosis and the services performed rather than from the chart. Where the score lands below the level billed, the claim is re-levelled and paid, not denied.
Reads every remittance. Matches every award to the payment.
Our 90-day look-back reports downcoding separately from denials. They are different problems, and you can currently only see one of them.
See what the 90-day look-back shows§Every number, next to the US benchmark
Colour begins where we pass it.
§What it doesn't do
Computes every deadline across the book to the business day.
Reads every remittance as it posts and matches code billed against code paid.
Screens a dispute for eligibility, then assembles the filing pack.
Ingests IDR determinations and matches each award to the payment that settles it.
Decide whether to file. Write a clinical position. Speak to a payer.
A named person does each of those, and the output is checked back against the determination it produced.
§Nothing expires silently
Miss one and nothing gets denied. The claim stops being collectable. Every date below is recalculated nightly, to the business day.
§And this is the whole book
Sample book · dates liveThe same five clocks on every open claim at once. None are denials. Each stops being collectable on a date if nobody works it.
§And this is the whole book
Sample book · dates liveThe same five clocks on every open claim at once. None are denials. Each stops being collectable on a date if nobody works it.
§And this is the whole book
Sample book · dates liveThe same five clocks on every open claim at once. None are denials. Each stops being collectable on a date if nobody works it.
Illustrative book. Claim identifiers and amounts are invented. The deadline arithmetic is real and recalculates against today's date.
§And this is the whole book
Sample book · dates liveThe same five clocks on every open claim at once. None are denials. Each stops being collectable on a date if nobody works it.
Illustrative book. Claim identifiers and amounts are invented. The deadline arithmetic is real and recalculates against today's date.
§The look-back report, three pages of it
Sample output · figures illustrativeThree pages answering what a denial-rate report cannot: which payer is taking what, and what your current reporting leaves out.
Each payer's own behaviour instead of one blended denial rate.
Mock-up dataBatching doubles on 1 Nov 2026
The cap on line items rises from 25 to 50, and what's allowed to be batched widens.
The trigger is the date open negotiation begins, not the filing date, so claims being paid now are already inside the window.
Filling a 50-item batch by hand is not realistic at volume. Ours are assembled automatically, then scored on whether the batch clears its own cost.
Filed alone, a $600 underpayment still does not pay: one dispute costs $515 in fees whoever brings it. Inside a batch of 50 the same claim carries $10 of cost and needs to be worth $12 to clear it. Batching is the change, not the fee. Most operations have not re-run their threshold since. Ours re-runs itself.
Seven questions an owner asks. On the left, what a standard vendor report answers.
Flexible reporting || Get what you need
§The risk isn't switching. It's switching badly.
We know the shape of it because we were brought in to repair one.
Deadline inventory
Every open claim is aged against its clocks before anything moves. Deadlines expiring during transition get worked first.
Parallel running
New claims start on our workflow while the outgoing vendor completes work in flight.
Aged A/R recovery
Legacy receivables are worked as a separate stream with its own reporting.
Weekly reporting
Collections, filing rates and deadline exposure, weekly. If the curve dips you see it in days.
§What changed this quarter
Most of what is written about out-of-network emergency rules online is two years stale.
The Fifth Circuit removes ghost rates from the QPA calculation
Placeholder rates for services a provider does not perform must be excluded from the qualifying payment amount. Bonus and incentive compensation must be included. Both push QPAs upward.
The agencies must now write new rules. No timeline has been set, and existing QPAs remain usable in the interim.
Patient cost-sharing is calculated off the QPA, so a larger share of every claim shifts into patient responsibility. The same opinion noted arbitration awards exceeded the QPA in 85% of disputes.
Federal IDR administrative fee drops from $115 to $15 per party
An 87% reduction, applying to disputes initiated on or after 11 June 2026. Claims that were uneconomic to pursue at $115 a side frequently are not at $15.
Expanded batching definition and a 50-item cap
The trigger is the negotiation start date, not the filing date, so claims being paid now are already inside the window. The cap rises from 25 line items to 50.
A 180-day deadline for Texas facility mediation
Out-of-network facilities must request TDI mandatory mediation within 180 days of receiving the initial payment. Before this there was no deadline at all.
§What freestanding emergency centers ask us first
How is FEC billing different from ordinary medical billing?
Freestanding emergency centers are overwhelmingly out-of-network, and the No Surprises Act prohibits balance billing patients for emergency care. Every payment dispute is resolved directly with the payer, through a formal process with hard deadlines. For most practices that is a side process. For an FEC it is the revenue cycle.
Federal IDR or Texas TDI: how is that decided?
By plan type, identified at the front of the process. Self-funded ERISA plans go to federal IDR. Fully insured Texas-regulated plans go to TDI, where facilities are routed to mandatory mediation and physicians to arbitration. Filing federally on a claim that belongs under state law is a leading cause of disputes being ruled ineligible.
What is the open negotiation period?
A mandatory 30-business-day window under the No Surprises Act, running from the insurer's initial payment. It must be initiated inside that window. If no agreement is reached, federal IDR becomes available, and that filing window is only four business days wide.
What does the free 90-day look-back involve?
A signed BAA, a claims extract covering the last 90 days, and no other commitment. The written report covers eligible-but-unfiled claims, downcoding patterns by payer, forum routing errors and estimated recoverable value. You keep it either way.
How are you priced?
Competitive, and always negotiable. It is a percentage of collections, quoted once we understand your volume and payer mix, and we will keep talking until it works for you. We would rather discuss net yield than headline rate. A lower percentage against weaker collections is the more expensive arrangement.
Where does automation sit in this?
In four places, none of them the decision. The Reconciler matches code billed against code paid on every remittance. The Filing Clock recalculates every statutory deadline nightly. The Case File screens eligibility and assembles the filing pack. The Ledger ingests IDR determinations and matches each award to the payment that settles it. Deciding whether to file, writing the clinical position and speaking to a payer are named people.
§Get started
One named person owns your book, and picks up.
Zain Baig
Director of Business Development
Request the 90-day look-back
We will send the scope and the BAA. No data changes hands until you have read both.
No PHI or claim detail in this form, please.