Methodology & Research
Our methods are written down, dated, and authored — the diagnostic framework, the scoring logic, and the payer intelligence behind every prioritization decision.
Methodology
Every open claim gets a recoverability score from likelihood of payment, dollar value, payer behavior and effort to resolve. The score drives the Fix & Revenue Queue — the highest-value, most-winnable claims get worked first.
Scope & limitations. Applies to open behavioral-health claims under active follow-up. A high score prioritizes work on the available evidence — it does not predict or guarantee payment; a low score may reflect missing information rather than true nonrecoverability. Scores are estimates, and they depend on data quality and payer behavior.
Put the score on your claims →Denial reason, payer pattern, timing.
Expected collectible vs. contracted.
Historical responsiveness & friction.
Steps, documentation, turnaround.
Diagnostic Framework
Seven checkpoints applied to every stuck claim. Claim-build integrity is verified before a problem is ever assigned to the payer, so we correct the right thing instead of appealing the wrong one.
Rejection Code
ERA / Remittance
Claim History
Payer Relationship
Provider Enrollment
Code Integrity
Claim Build
Payer behavior we track
Policy is one thing; how a plan actually pays is another. What it delays, how it routes money, the errors it makes quietly — that gap is where recovery happens.
When a provider does not actively enroll in Optum Pay ACH, UnitedHealthcare defaults them to virtual card payments that can skim up to 5 percent in fees on every remit. Electing ACH stops the leak.
When a carrier trims out-of-network coverage, it usually only touches fully-insured plans, where the payer carries the risk. Self-funded employer plans are administered, not owned, so the same member may still have benefits. Which one a patient holds changes the strategy.
We watch payer system errors, not just individual denials. When one carrier's system started reading an IOP code as its higher-authorization version and denying for no auth, the fix was to keep submitting so the claims reprocessed, not to appeal each one.
Many carriers and Medicaid plans hand behavioral health to a separate manager, such as Optum, Carelon, or Magellan. Confirming who really processes the claim at eligibility, before you submit, heads off a whole category of routing denials.
Payer intelligence is not a report you file away. It is knowing, before you submit, exactly how this plan is going to behave. Explore HRI Insights →
From the desk
Dated observations from the claims we're working right now — patterns worth checking your own book for. Never client information, never a payer policy statement.
Jul 19, 2026
PB
On out-of-network residential claims we keep finding UnitedHealthcare-administered plans, UMR included, either parking claims in post-service review or issuing payment to the member instead of the facility. If the portal says paid and no deposit ever landed, ask the family before you write an appeal — the check may be sitting in their mailbox.
Jul 19, 2026
PB
Several aged-receivable recoveries this month show the same shape: claims that were fixable, sitting in 'follow-up' while filing and appeal windows closed on part of the balance. Pull the 120-day-plus aging and check every payer's filing clock against it this week. The recoverable tail shrinks monthly, and it never announces itself.
Jul 15, 2026
CR
We traced one program's missing Blue-plan revenue to an enrollment gap that let institutional claims clear the clearinghouse and die quietly at the payer's front end. Nothing looked wrong until the aging did. If claims go out and no rejection ever comes back, treat the silence as the alarm.
Built on infrastructure
Payer intelligence, scoring logic, and a documented framework — the structure that turns scattered denials into prioritized, recoverable revenue.
How the method holds up
Every open claim gets a recoverability score built from likelihood of payment, dollar value, payer behavior, and the effort it will take to resolve. That score drives the Fix & Revenue Queue, which means the highest-value, most-winnable claims get worked first. It applies to open behavioral-health claims under active follow-up.
No. A high score prioritizes work on the available evidence; it does not predict or guarantee payment. It cuts the other way too, because a low score may reflect missing information rather than a claim that is truly unrecoverable. Scores are estimates, and they depend on data quality and payer behavior.
We verify claim-build integrity before a problem is ever assigned to the payer, so the right thing gets corrected instead of appealing the wrong one. Seven checkpoints get applied to every stuck claim, running from the rejection code and remittance data through claim history, payer relationship, provider enrollment, code integrity, and the claim build itself.
Knowing, before you submit, exactly how a plan is going to behave. Policy is one thing; how a plan actually pays is another, and we track what it delays, how it routes money, and the errors it makes quietly, because that gap is where recovery happens. One example: many carriers and Medicaid plans hand behavioral health to a separate manager such as Optum, Carelon, or Magellan, and confirming who really processes the claim at eligibility heads off a whole category of routing denials.
It is written down, dated, and authored — the diagnostic framework, the scoring logic, and the payer intelligence behind every prioritization decision are all documented. The claim scoring specifically runs on Methodology v1.0, written by Christopher Ryan and reviewed by Peter Busch. Calibration gets reviewed as outcome data grows.
Want the methodology applied to your claims?
Send a little context and we'll baseline your open claims, score what's recoverable, and show you which ones are worth working first.
No PHI, please — keep patient data off the public form. Secure information is requested only after the appropriate intake and contracting process.
Last updated: August 13, 2026