Step 01
We start by signing the documents that keep you and us safe
We start every engagement with three documents. We don't move until they're in place.
- HIPAA BAA. We're required by law to have this in place before a single claim line moves. Read more about our HIPAA program.
- Letter of authorization. This names us your authorized representative with the TPA.
Engagement file · day oneSample
DOC 1Services agreement, fee on recovery onlySigned
DOC 2HIPAA business associate agreementExecuted
DOC 3Letter of authorization to the TPAOn file
Legal standing with the TPA from day one.
Claims feed · TPA syncIllustrative
CLM-2201Inpatient stay, 4 days$68,410Parsed
CLM-2202Outpatient surgery$24,120Parsed
CLM-2203Emergency visit$11,890Queued
SPD-26Summary plan descriptionOn file
Claims synced2,847
Figures are illustrative.
Step 02
You send us your books
The TPA releases the full claims history.
- Full history. We pull EOBs, remittance data, and itemized bills for large claims, plus the summary plan description.
- Real benchmarks. We score every claim against independent cost benchmarks.
- Nothing left behind. Every claim is scored and queued, so no bill slips through unreviewed.
Step 03
Now we review every line
We request the itemized bill and compare it against the EOB, the plan document, and clinical standards.
- Line-level detail. Every line carries a code, so we catch the errors in the comparison.
- Clinical review. A dispute without clinical justification loses. Ours are written to the record.
- The odds are good. Industry audits find errors on roughly 4 of 5 hospital bills.
Line-item scan · itemized billIllustrative
Duplicates. The same service billed twice.Flagged
Upcoding. Billed at a higher level than performed.Flagged
Unbundling. One procedure split into many codes.Flagged
Never rendered. Charges for care that did not happen.Flagged
Wrong codes. Diagnoses that trigger higher payouts.Flagged
Balance billing. Billing for what the plan already paid.Flagged
Error patterns checked6
Every line checked against the EOB and the plan document.
Dispute · claim #8471-CIllustrative
Day 0Dispute filed with provider billingFiled
Day 12Provider acknowledges receiptReceived
Day 41Corrected claim resubmittedCorrected
Day 58Refund posted to the plan's fundRecovered
Returned to the plan+$8,540
Figures are illustrative.
Step 04
We document every potential dispute
Precise to the exact line, exact code, exact reason.
- Deadlines tracked. Providers typically respond in 30 to 60 days. TPAs reprocess in about 30. We hold both to it.
- TPA errors too. We don't let adjudication mistakes get a pass; they get a claim adjustment request as well.
Step 05
We send back a full report
We show claims audited, errors documented, dollars recovered, our fee, and your net savings.
- Every quarter. We send one document: every dispute, tracked to the dollar.
- The audit never ends. We watch every new claim until the end of the fiscal quarter you signed with us, and nothing ages out of the recovery window.
- Provider intelligence. We score clean-claim rates and flag watchlist providers so you know who bills honestly.
Recovery report · Q2Illustrative
LINE 1Claims reviewed$854,210Audited
LINE 2Recovered to the plan$348,910Returned
LINE 3Fee, 25% of recovered$87,228Documented
Net savings to the plan$261,682
Figures are industry-benchmark illustrations, never client data.