Sample Audit Report
Anonymized data from a real claims analysis
Sample Data
apruvl
Sample Medical Practice
Claims Audit Report
Jan 1, 2026 - Jun 30, 2026
Your Recoverable Revenue
$142,300
Based on 2,847 claims analyzed, Jan 2026 - Jun 2026
Sample Data
apruvl
Executive Summary
2,847
Total Claims
432
Total Denied
$1,234,500
Total Billed
$187,200
Total Denied Amount
15.2%
Denial Rate
Industry avg: 7-8%
$165,800
Appealable Amount
$21,400
Timely Filing Losses
$142,300
Est. Recoverable
Denial Breakdown by Category
Eligibility
$52,400
Medical Necessity
$41,800
Coding Error
$38,600
Authorization
$28,200
Timely Filing
$21,400
Duplicate
$4,800
Sample Medical Practice's denial rate of 15.2% is significantly above the industry average of 7-8%. Out of $187,200 in total denied claims, $165,800 is potentially appealable. Applying the industry average appeal overturn rate of 43%, the estimated recoverable revenue is $142,300.
Sample Data
apruvl
Denial Reasons
| CARC | Description | Count | Amount | Appealable |
|---|---|---|---|---|
| CO-197 | Precertification/authorization/notification absent | 87 | $42,600 | Yes |
| CO-16 | Claim/service lacks information needed for adjudication | 74 | $36,200 | Yes |
| CO-4 | The procedure code is inconsistent with the modifier used | 62 | $28,400 | Yes |
| CO-50 | Non-covered services / not deemed medically necessary | 58 | $27,800 | Yes |
| PR-27 | Expenses incurred after coverage terminated | 51 | $24,600 | Yes |
| CO-29 | Timely filing limit has expired | 44 | $21,400 | No |
| CO-18 | Exact duplicate claim/service | 32 | $4,800 | No |
| OA-23 | Payment adjusted: authorized amount exceeded | 24 | $1,400 | Yes |
Appealable Amount
$165,800
Non-Recoverable Amount
$21,400
43% industry average appeal overturn rate applied to appealable amount to estimate recoverable revenue.
Sample Data
apruvl
Payer Analysis
| Payer | Claims | Denied | Denial Rate | Denied Amt | Top Reason |
|---|---|---|---|---|---|
| Blue Cross Blue Shield | 842 | 147 | 17.5% | $72,400 | CO-197 Auth absent |
| Aetna | 634 | 108 | 17.0% | $54,200 | CO-16 Lacks info |
| UnitedHealthcare | 521 | 62 | 11.9% | $31,800 | CO-4 Modifier issue |
| Cigna | 418 | 58 | 13.9% | $18,600 | CO-50 Medical necessity |
| Medicare | 312 | 38 | 12.2% | $7,400 | CO-16 Lacks info |
| Humana | 120 | 19 | 15.8% | $2,800 | PR-27 Coverage terminated |
Denial Rate by Payer
Sample Data
apruvl
Recommendations
1
Appeal BCBS prior authorization denials
Authorization
Action:
87 claims denied for missing prior auth (CO-197) represent $42,600. Many of these had active authorizations on file. Submit appeals with auth reference numbers and dates of service within 30 days.
Expected Impact:
Estimated recovery of $18,300 based on 43% overturn rate for authorization-related appeals.
2
Resubmit claims with missing information
Coding Error
Action:
74 claims denied under CO-16 can often be corrected and resubmitted. Review each for missing diagnosis pointers, referring provider NPI, or place of service codes. Most of these are data entry issues, not clinical disputes.
Expected Impact:
Estimated recovery of $27,100 -- corrected claims have a higher overturn rate (75%+) since the fix is administrative.
3
Fix modifier usage patterns
Coding Error
Action:
62 claims denied for modifier inconsistency (CO-4). Common pattern: missing modifier 25 on E/M codes billed same-day as procedures. Update billing workflow to flag same-day E/M + procedure combinations before submission.
Expected Impact:
Prevent an estimated $4,700/month in future denials by catching modifier issues before submission.
4
Implement eligibility verification workflow
Eligibility
Action:
51 claims denied because coverage had terminated (PR-27). Implement real-time eligibility checks at scheduling and day-of-service to catch inactive coverage before rendering services.
Expected Impact:
Prevent an estimated $4,100/month in eligibility-related denials going forward.
Sample Data
apruvl
Methodology & Disclaimer
How This Analysis Was Performed
Your claims data was parsed, normalized, and analyzed by apruvl's automated audit engine. Each claim was categorized by status, payer, denial reason (CARC code), and procedure code. Denial patterns were identified and quantified.
Data Used
This report is based exclusively on the claims file you uploaded. No external data sources were consulted. Patient identifiers were hashed using SHA-256 and never stored in plaintext.
Recoverable Revenue Estimate
The recoverable revenue figure applies the industry average appeal overturn rate of 43% to the total appealable denied amount. This is a conservative estimate. Timely filing denials are excluded from the recoverable amount as they are not eligible for appeal. Actual recovery depends on your specific payer contracts, appeal quality, and supporting documentation.
This report is based on claims data provided by your practice and does not constitute legal, financial, or medical billing advice. CARC code interpretation and recoverability estimates are based on industry averages and may not reflect your specific payer contracts. apruvl recommends engaging a certified medical billing professional for implementation.
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