Score every claim before you submit it.
Know which claims will be denied and why, before they leave your billing system.
Prexisio trains a pattern model on your adjudicated claims history, then scores every pre-submission claim against it. Your billing team receives a prioritized work order with specific interventions for every HIGH risk and CERTAIN denial claim. Monthly, your billing director receives a Pattern Report surfacing the structural denial drivers across payers, procedures, and diagnosis codes.
Two deliverables. One analyst. No software for your team to manage.
Which claims in this batch will be denied before you submit them?
Prexisio trains a pattern model on your adjudicated claims history, then scores every claim in your pre-submission batch. HIGH risk claims surface with a specific intervention. Certain denials are blocked before they reach the payer.
The billing team receives a prioritized work order. CERTAIN denials at the top, HIGH risk next, each with the exact action required before submitting.
See how Prexisio delivers this for your practicePrexisio uses your adjudicated claims history to train a pattern model, then scores every pre-submission claim against it. Your team uploads a file. Prexisio does the rest.
You find out a claim was denied weeks after submitting it.By then, it is usually too late to fix easily.
The denial pattern was visible in the data before the claim left the billing system. Prexisio finds it there — before submission, not after adjudication — so the billing team can intervene when it still matters.
- Claims are submitted without knowing which will be denied. The denial comes back 30 to 45 days later — after the timely filing window has narrowed and the billing team has moved on to the next batch.
- The same denial patterns repeat across submission cycles. Authorization failures, deleted diagnosis codes, modifier issues, and payer-specific bundling rules fire again and again because nobody can see the pattern before submission.
- HIGH risk claims are mixed in with LOW risk claims and submitted together. The billing team has no way to separate them and intervene before the claim reaches the payer.
- By the time denial reports surface in the EHR or practice management system, the damage is already done. Leadership can see denial volume but cannot see which denials were preventable or which payer-procedure combinations are systematically breaking down.
- Payers accept claims and pay less than the contracted rate. Without comparing allowed amounts to paid amounts across payer, CPT code, and procedure type, the underpayment sits inside remittance data and goes undetected.
- There is no forward-looking view. Revenue intelligence at most practices is retrospective — what denied last month — not predictive — what is about to deny from this week's submissions.
What Prexisio answers
The questions your billing team and leadership need answered every submission cycle.
Two deliverables. One serves the billing team working claims before submission. The other serves the billing director and practice administrator making structural decisions about payer relationships and denial patterns.
Which claims in this pre-submission batch are most likely to be denied?
Every claim in your pre-submission batch gets a risk score built from your practice's own history with that payer and procedure. HIGH risk and CERTAIN denial claims surface at the top of the work order before the claim reaches the payer.
What does the billing team need to do before submitting each flagged claim?
Each HIGH risk claim comes with the specific action required before submitting — not a category label. Get authorization for this claim. Fix this modifier. Replace this diagnosis code. The billing team works top to bottom without interpretation.
Which payer-procedure combinations are systematically denying across this practice?
Your practice's own claims history reveals which payer-procedure combinations are denying at the highest rates. Aetna PPO and CPT 64483 at 42%. UHC and CPT 64635 at 35%. Named, specific, and actionable — not described generically.
Which payers are paying below their contracted rate on paid claims?
A low denial rate from a payer does not mean you are being paid correctly. The Pattern Report flags payers where what was actually paid is consistently below what that plan type is expected to pay — and recommends which contracts to audit first.
What should the billing director address first, and in what order?
The Pattern Report delivers four named actions: eliminate the highest-dollar denial driver, reduce the second driver, raise the specific payer with the largest payment gap, create the missing workflow. Each references a named payer or procedure, not a general recommendation.
Are any claims about to exceed timely filing limits or carry deleted diagnosis codes?
Two categories of claims will be denied with certainty regardless of clinical accuracy or coding quality: those submitted after the payer's timely filing window, and those carrying ICD-10 codes deleted from the current code set. Prexisio catches both before submission.
Everyone else works the denial after it happens.Prexisio catches it before submission.
RCM vendors, denial management tools, and EHR analytics are all looking at the same retrospective data. Prexisio is the only layer that sits upstream — scoring claims before they leave the billing system and surfacing the structural patterns driving denials before they repeat.
What Prexisio delivers
- Every pre-submission claim scored against this practice's own denial history — specific to your payers, your procedures, your patterns, not industry averages
- CERTAIN denials blocked before submission: timely filing violations, deleted ICD codes, and hard regulatory pre-checks
- HIGH risk claims surfaced with a specific named intervention — authorization required, modifier corrected, ICD replaced — not a generic denial category
- Payer underpayment flagged by comparing actual payment ratios to expected rates by plan type, not by comparing individual claims
- Monthly Pattern Report showing which payer-procedure combinations are systematically denying and which payers are paying below contract
- Work order delivered in Excel with priority ordering — CERTAIN first, HIGH by dollar, MEDIUM, LOW — ready for the billing team to action
- No software for the practice to deploy, no dashboard for the team to manage, no analyst hire required
Submit claims, work denials, manage collections, and support billing operations.
RCM vendors are reactive by design — they work denials after adjudication. Prexisio is pre-submission. The claim risk score reaches the billing team before the claim reaches the payer.
Report on encounters, appointments, and activity inside the EHR.
EHR reports show what happened inside one system. Prexisio's pattern model is trained on the intersection of payer, CPT, ICD, and provider across your adjudicated claims history — not a single-system view.
Categorize and work denials after adjudication, and track appeal status.
Denial management tools help after the claim has been denied. Prexisio works upstream — the same denial pattern is detected before submission so the billing team intervenes while the claim can still be fixed.
Assess operations, recommend process changes, and advise leadership teams.
Consulting engagements surface patterns once. Prexisio scores every pre-submission batch and delivers a new Pattern Report each period. The intelligence is recurring, not one-time.
How Prexisio works.
One analyst. Two deliverables. The practice uploads a file. Prexisio handles the model, the scoring, the analysis, and the delivery.
Share 12 months of adjudicated claims
Prexisio analyzes your adjudicated claims history — what was billed, what was allowed, what was paid, which claims denied and why. The intelligence is built from your practice's own data, not industry averages. Your payers, your procedures, your denial patterns.
One CSV file. No EHR integration required. No data warehouse. The analyst handles everything from here.
Upload your pre-submission batch
Before each submission run, the billing team uploads the pre-submission claims file. Every claim is scored. Timely filing violations and deleted ICD codes are blocked as CERTAIN denials before any risk scoring occurs. HIGH risk claims surface with a named intervention.
The same file your billing team already exports from the practice management system.
Receive the prioritized work order
The billing team receives a scored work order in Excel. CERTAIN denials at the top — do not submit. HIGH risk claims next, each with a specific required action. MEDIUM and LOW below. The analyst approves the work order before it goes out.
The billing team works top to bottom. No interpretation required.
Receive the monthly Pattern Report
Each period, the billing director and practice administrator receive a Pattern Report derived from the same graph model. It names the specific payer-procedure combinations driving the highest denial rates, surfaces payers paying below contract, and delivers four named recommended actions.
Strategic intelligence for the billing director. Operational intelligence for the billing team. One analyst. Two deliverables.
Who we serve
Built for specialty practices with high procedural claim volume.
Prexisio works where denial patterns are specific to procedure codes, payer behavior, and authorization requirements — not generic across all of healthcare.
Pain Management
- Pre-submission scoring on interventional procedures with high Aetna and UHC denial rates
- Authorization pre-checks for CPT 64483, 64490, 64493, 64635 before submission
- Pattern intelligence on which payer-procedure combinations are systematically denying
- Underpayment signals for payers paying below contract on paid interventional claims
Gastroenterology
- Pre-submission risk scoring on high-volume endoscopy and procedural claims
- Authorization and eligibility pre-checks before GI procedural submissions
- Pattern intelligence across payer, CPT, and diagnosis code combinations
- Underpayment detection on paid colonoscopy, EGD, and procedural claims by payer
Spine Surgery
- Pre-submission scoring on complex surgical claims with authorization and coding risk
- Hard block detection for timely filing violations on delayed spine surgical claims
- Pattern intelligence on high-value procedure denial rates by payer and surgeon
- Underpayment signals on implant and surgical procedure claims by commercial payer
Orthopedics
- Pre-submission risk scoring across clinic, ASC, and surgical claim types
- Authorization and modifier pre-checks for orthopedic procedural codes
- Pattern intelligence on payer-procedure denial rates by site of service
- Underpayment detection across implant, surgical, and office visit claims by payer
Proof of work
Built from real analytical work inside specialty healthcare.
The patterns Prexisio surfaces now — denial drivers by payer and procedure, underpayments hidden inside paid claims — came from the same work that built the underlying analysis.
$2M in underpayments sitting inside paid claims no one had measured.
A multi-site pain management organization came in asking about procedure volume and denial rates. Standard reporting showed claims were being paid. It did not show whether they were being paid correctly.
Comparing contracted allowed amounts against actual payments revealed a systematic underpayment gap across several payers — revenue that had been earned, billed, and technically paid, but at rates below what the contracts required.
The same engagement surfaced the denial patterns driving the practice's overall denial rate above benchmark — specific payer-procedure combinations that were denying at disproportionate rates and repeating across submission cycles.
$2M+
Underpayment gap identified through payment analysis
28%
Overall denial rate at engagement start vs 15% benchmark
4
Payer-procedure combinations flagged as primary denial drivers
Seven acquired GI practices. No unified view of denial patterns across payers.
A PE-backed GI management services organization had acquired multiple practices across different markets. Each brought its own payer mix, claims history, and billing patterns.
Leadership needed a way to see denial patterns, payment variance, and billing performance across the entire organization — not just inside each practice's own reporting. The individual practice views were clean. The cross-practice view did not exist.
The work built a unified recurring intelligence layer across the acquired practices and surfaced which payers and procedure codes were creating the largest denial exposure across the organization.
7+
Acquired GI practices unified for recurring intelligence
Monthly
Recurring denial and payment pattern reports delivered
3
Payers identified as consistent underpayment sources
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Stop finding out a claim was denied after you submitted it.Score every claim before it leaves your billing system.
Prexisio delivers two things: a scored work order for the billing team before each submission run, and a monthly Pattern Report for the billing director showing the structural denial patterns across payers, procedures, and diagnosis codes. One analyst. No new software for your team to manage.