⚠ Sample  ·  Synthetic demo data — not a real client  ·  illustrative of a typical Apex Flow audit output
Apex FlowRevenue Cycle Solutions
Sunrise Pain & Spine
Forensic A/R Audit · de-identified view
data as of 2026-06-25
Forensic A/R Audit · Findings

Here's what we found in your A/R.

A live picture of your denied dollars — what we've recovered, what's still in play, and what's leaking out if nothing changes. Every figure below is computed by the Apex Flow engine from your own claim data.

Identified at stake
$20,195
30 of 32 claims flagged recoverable
Still recoverable
$11,435
open balance we're actively working
Recovery rate · closed
86.1%
$7,540 recovered so far
01

Where your $20,195 is going

Your denied and at-risk dollars, split three ways: already recovered, still in play, and leaking out the bottom.

Recovered
$7,540
37.3% of at-stake
Still recoverable
$11,435
56.6% of at-stake
Leaking / written off
$1,220
6.0% of at-stake
$7,540 recovered + $11,435 still recoverable + $1,220 leaking = $20,195 at stake
02

The clock — your open A/R by age

Older balances collect at sharply lower rates. This is the $11,435 you're still actively working, sorted by how long it's been sitting.

61–90 days
$360
91–120 days 90+ danger zone
$4,965
120+ days 90+ danger zone
$6,110
96.9% of your still-open A/R is 90+ days old. Recovery probability drops with every aging bucket — this is the money most at risk of becoming permanent.
$360 + $4,965 + $6,110 = $11,435 open balance · matches "still recoverable" above
03

Where your open A/R is stuck

The same $11,435 — now broken out by why each claim is sitting. This tells us what kind of work it takes to free it.

Medical necessity / coverage appeal
$4,565
Prior auth / timely conditional on proof
$4,365
Coding / administrative correct & resubmit
$1,560
Other needs review
$635
Low likelihood
$310
$4,565 + $4,365 + $1,560 + $635 + $310 = $11,435 · every open dollar accounted for, same base as the aging above
04

The recovery plan

Your top 3 open denial codes by dollars — how we recover each one now, and how we stop it from recurring.

CO-197Auth / precert absent or invalid
$4,075
6 claims affected
↻ Recover

Evidence-backed appeal citing the payer's own coverage policy.

If unaddressed, est. $1,083–$2,012 next quarter — still-open at-stake annualized to a quarter, ±30% (not a guarantee).
CO-50Non-covered / not medically necessary
$3,550
4 claims affected
↻ Recover

Coverage-policy match + ABN-evidence appeal on the open balance.

If unaddressed, est. $944–$1,753 next quarter — still-open at-stake annualized to a quarter, ±30% (not a guarantee).
CO-16Missing / incomplete / invalid information
$1,130
4 claims affected
↻ Recover

Correct the missing / invalid field and resubmit a clean claim.

If unaddressed, est. $300–$558 next quarter — still-open at-stake annualized to a quarter, ±30% (not a guarantee).

Top 3 of 11 open denial codes by dollars ($8,755 of the $11,435 shown). Every still-open claim is counted in "Where your open A/R is stuck" above.

05

Proof — a few we already fixed

A sample of claims from this engagement recovered in full. De-identified — no patient data.

Claim A
CO-50
Coverage-policy match + ABN-evidence appeal on the open balance.
✓ Recovered in full$2,450
Claim B
CO-197
Evidence-backed appeal citing the payer's own coverage policy.
✓ Recovered in full$1,850
Claim C
CO-50
Coverage-policy match + ABN-evidence appeal on the open balance.
✓ Recovered in full$920

A sample of what's been recovered so far — part of the $7,540 closed to date.

06

You vs the standard

Industry denial & appeal dynamics across payer types (Medicare Advantage, ACA, commercial). Your traditional-Medicare / WISeR-specific numbers are in your own claim detail above.

Most practices appeal 1 in 9 denials. More than 4 in 5 appeals win.
Denials that actually get appealed11.5%
Appealed denials that get overturned80.7%
→ That gap between appealed and overturned is the money we go get. Most practices never appeal. We do.
19%
In-network denial rate
ACA Marketplace (HealthCare.gov) in-network claims, 2024
KFF analysis of CMS transparency data
14.8%
All-claims denial rate
Pennsylvania fully-insured market, 2025 Transparency in Coverage report
Pennsylvania Insurance Department
41%
Providers with >10% of claims denied
Share of surveyed providers reporting >10% denied, 2025
Experian Health · State of Claims 2025
7.7%
MA prior-auth denial rate
MA prior-auth requests fully/partially denied, 2024 (4.1M of ~53M)
KFF analysis of CMS MA data
80%+
Prior-auth appeals that succeed
Prior-auth appeals that succeed — the case for appealing more
American Medical Association
80.7%
Appealed denials overturned
Appealed MA prior-auth denials fully/partially overturned, 2024
KFF analysis of CMS MA data
07

How to trust these numbers

A forensic audit is only worth the rigor behind it. Here's the standard every figure on this page is held to.

Every figure here is computed by the Apex Flow engine from your own claim data — not estimated, not typical-practice averages.
No fabricated numbers. Industry comparisons cite their sources; any forward-looking figure is explicitly labeled an estimate with a stated range.
De-identified view — PHI never leaves your office. We work claim-level financial data, not patient records.
A human reviews every recommendation. Nothing is auto-executed against your payers.

We don't just recover — we patch the leak

🛡
CO-197 — root-cause review of this denial family + targeted coder education.
🛡
CO-50 — coverage-policy match + ABN workflow before the service is rendered.
🛡
CO-16 — front-end field validation: NPI, dx pointers, demographics scrub before the claim leaves.

This is a sample. Imagine it on your numbers.

We run the same forensic audit on your real denied and aging claims — free, no obligation, and the findings are yours to keep. You only pay a percentage of what we actually recover.

Book your free A/R audit →
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