Illustrative Scenarios

Illustrative Scenarios.
Real Billing Patterns.

These scenarios are illustrative composites built from common billing problems in each specialty. They are not results from named or identifiable clients, and your results will vary. Specialty, size and location details are examples only.

31%
Illustrative collections increase
18 days
Illustrative A/R reduction
67%
Illustrative denial rate drop
60 days
Illustrative time to measurable ROI
Orthopedic Surgery Illustrative scenario Example: 4-physician practice · 2,800 visits/month

Orthopedic Practice Cuts Denial Rate from 14.2% to 2.8% in 60 Days

The situation: A four-surgeon orthopedic group had been with the same billing company for 6 years. Their denial rate had crept to 14.2%, nearly double the specialty average. The primary causes were global period violations, missing modifier 59 on same-day procedure combinations, and prior auth lapses for arthroplasties. $340,000 was sitting in AR over 90 days.

Before: 14.2%
↓
2.8%
Denial Rate
Before: 47 days
↓
19 days
Days in AR
Before: 81%
↑
97.2%
Net Collection Rate
Week 1–2
Full EHR integration + 90-day AR audit. Identified $227K in recoverable aged claims.
Week 3–4
Prior auth workflow rebuilt. All scheduled arthroplasties cleared with auth before OR date.
Day 60
Denial rate at 3.1%. $189K recovered from aged AR. Days in AR reduced to 22.
Day 90
Denial rate 2.8%. Full AR under 30 days at 74%. Collections up 28% vs. prior quarter.

Scenario: a practice finds revenue it didn't know it was missing. Within 30 days of a billing clean-up, claims go out cleaner, and the AR recovery alone covers the first year of fees.

Illustrative scenario, composite of common feedback

Mental Health / Behavioral Health Illustrative scenario Example: 12-clinician group practice · 3,400 sessions/month

Behavioral Health Group Recovers $412,000 in Missed Collections Over 12 Months

The situation: A large behavioral health group practice with psychiatrists, psychologists, and LCSWs was billing through a generic medical billing company with no behavioral health expertise. The practice was systematically misbilling MBHOs as medical benefits, under-coding E/M services by psychiatrists, and failing to bill add-on codes (90833) for combined medication management and psychotherapy visits. Estimated revenue leakage: $34,000/month.

Before: 18.6%
↓
3.4%
Denial Rate
Before: $412/visit
↑
$541/visit
Avg. Reimbursement
Before: 53 days
↓
24 days
Days in AR
Week 1
MBHO carve-out mapping completed for all 8 major payers. Billing entity corrected for 1,200+ patients.
Week 3
90833 add-on code workflow implemented. $28K/month in previously unbilled combined visit revenue captured.
Month 3
Denial rate below 5%. 6-month AR backlog worked down by 71%.
Month 12
$412K total recovery documented. Denial rate steady at 3.4%. Practice added 3 clinicians on strength of improved cash flow.

Scenario: a behavioral health group's claims route wrongly because the old biller misses MBHO carve-outs. Fixing the routing in the first week improves cash flow visibly by month two.

Illustrative scenario, composite of common feedback

Gastroenterology Illustrative scenario Example: 3-physician practice · 1,600 procedures/month

GI Practice Adds $19,200/Month by Correctly Billing Screening-to-Diagnostic Colonoscopy Conversions

The situation: A 3-physician GI practice was billing all colonoscopy procedures with a single code regardless of findings. When a screening colonoscopy identified and removed polyps, converting the claim from screening to diagnostic, the practice was not applying the correct CPT code change, modifier PT, or -33 where applicable. This single error was systematically underbilling every polyp removal case.

Before: $187 avg
↑
$299 avg
Colonoscopy Reimbursement
Before: 11.8%
↓
3.1%
Denial Rate
Before: $0/mo
↑
$19,200/mo
New Monthly Revenue Captured
Week 1
Coding audit of 3 months of colonoscopy claims identified 412 underbilled polyp removal cases.
Week 2–3
Corrected billing workflow implemented. Pathology coordination protocol established.
Month 2
$38,400 recovered from retroactive rebilling of correctable past claims within timely filing windows.
Ongoing
$19,200/month in additional revenue from correct screening-to-diagnostic conversion billing.

Scenario: a single recurring coding error quietly costs a practice $230,000 a year. A billing review catches it in the first week, after four years of it going unflagged.

Illustrative scenario, composite of common feedback

Pain Management Illustrative scenario Example: 2-physician practice · 900 procedures/month

Pain Management Practice Recovers $178,000 in Aged AR: Practice Had Written It Off

The situation: A 2-physician interventional pain practice switched to Rcmaxis after their previous biller stopped actively working claims older than 90 days, effectively writing off all aged AR as uncollectable. Rcmaxis inherited $178,000 in claims between 90 and 180 days old at transition. The previous biller had classified these as "write-offs." Most were still within timely filing windows for appeal.

Written off: $178K
↑
$143K
Aged AR Recovered
Before: 14.9%
↓
3.7%
Denial Rate
Before: 61 days
↓
21 days
Days in AR
Week 1
Full AR audit. 847 claims identified as potentially recoverable. Prioritised by payer timely filing deadline.
Week 2–6
Systematic appeal submissions. 6 peer-to-peer reviews with medical necessity support documentation.
Month 3
$143,000 collected from previously written-off claims, 80% recovery rate on worked aged AR.
Month 6
Forward denial rate at 3.7%. Prior auth workflow rebuilt. New claims processing within 24 hours.

Scenario: a practice is told its aged AR is uncollectable. A structured recovery effort brings back $143,000 of it in 90 days, enough to cover two years of billing fees.

Illustrative scenario, composite of common feedback

Your practice could be the next case study.

We offer a free, no-obligation revenue assessment for qualified practices. We'll audit your last 90 days of claims and show you exactly what you're leaving on the table, with numbers, not estimates.

Get Your Free Revenue Audit