REVENUE AT RISK: 3 patients with unreviewed CRITICAL findings have upcoming discharges — estimated HRRP exposure: $47,000 · 2 unaddressed prior auth gaps — est. denial exposure: $112,400
Net Collection Rate target >95%
96.2%
↑ +0.4% vs last month · Teal = optimized
Days in AR target <40
43.1
↑ +3.1 days over benchmark
Denial Rate target <5%
7.3%
↑ Benford anomaly flagged on Digit 5
Charge Lag
2.1d
target <3 days ✓
Cost to Collect
$24
target <$30 ✓
Prior Auth Rate
94.1%
target >98% ⚠
DNFB
1.7d
target <2 days rev ✓
A/R Aging 43.1 DAR
0–30 Days
$2.4M
1,847 claims
31–60 Days
$890K
612 claims
61–90 Days
$341K
228 claims
90+ Days
$187K
94 claims ⚠
Top Denial Reasons by $ at Risk 7.3% rate
| CARC Code | Description | $ at Risk | Volume |
|---|---|---|---|
| CO-50 | Medical necessity not supported | $82,400 | |
| CO-97 | Included in another service (NCCI) | $61,200 | |
| CO-11 | Dx inconsistent with procedure | $44,800 | |
| CO-4 | Procedure/modifier mismatch | $28,100 | |
| PR-96 | Non-covered charge | $12,600 |
Benford's Law — Claims Digit Distribution NON-CONFORMING
12345
6789
Observed
Expected (Benford)
chi² = 18.4 · p = 0.0031 · MAD = 0.021 — DIGIT 5 ELEVATED (+3.5%) · BLUE SHIELD CLAIMS · Possible shadow-policy trigger. Escalate to payer relations.
HRRP Readmission Exposure $47K EST.
Heart Failure
1.38x
Pneumonia
1.12x
AMI
0.91x
COPD
0.87x
THA/TKA
0.82x
CABG
0.76x
Estimated Penalty Exposure
$47,000
Prior Authorization Queue 94.1% approval rate
Adalimumab (Humira) — P008
Blue Shield · DRG 569 · $5,200/mo
Pembrolizumab (Keytruda) — P003
Aetna · Oncology · $18,400/cycle
Semaglutide (Ozempic) — P005
UnitedHealth · T2DM · $892/mo
Eliquis 5mg — P010
Cigna · AF/DVT · $380/mo
Dupilumab (Dupixent) — P007
Medicare Advantage · $3,100/mo
Claim Splitting Tool — NCCI Unbundler NCCI Q2 2026
Enter CPT code pairs to check NCCI bundling and get modifier guidance.
CPT 99213 (E&M Level 3) + 93000 (ECG with interpretation)
CCMI 1 — Codes may be reported together with correct modifier.
Recommended: Append Modifier 25 to 99213 — significant, separately identifiable E&M same day as diagnostic procedure.
✓ Do NOT use Modifier 59 on E&M services. Modifier 25 is required.
CCMI 1 — Codes may be reported together with correct modifier.
Recommended: Append Modifier 25 to 99213 — significant, separately identifiable E&M same day as diagnostic procedure.
✓ Do NOT use Modifier 59 on E&M services. Modifier 25 is required.