Historical Revenue Integrity Audit
What did we find in your historical revenue path?
BritepathHistorical Revenue Integrity Audit
Prepared for BigBoy Podiatry PLLC · Dallas, TX
September 9, 2026
- Practice
- BigBoy Podiatry · 4 providers · 2 locations
- Audit period
- Sep 1, 2024 – Aug 31, 2026
- Source system
- eClinicalWorks export · 09/01/2026
- Claims analyzed
- 41,286
- Service lines analyzed
- 68,914
- Remittances · payments analyzed
- 37,102 · 36,004
- Contracts / fee schedules available for analysis
- 6 of 9 payers under written agreement (Curative, UHC, BCBS TX, Aetna, Cigna, Humana); Medicare and Texas Medicaid priced from fee schedules; no Oscar contract provided.
Identified potential financial variance
- Contract variance
- $128,640
- Payment variance
- $61,215
- Other quantified revenue gaps
- $29,370
164 processing gaps require review · amount unknown 218 records have insufficient evidence
Across the period the practice collected on 89.0% of submitted claims, at a net collection rate of 96.1% and $126.40 allowed per visit, with a median 27 days to payment.
We reconstructed the available historical claim and payment path and compared payer activity with the applicable financial rules and source records. The amounts above represent identified potential differences, not money already recovered. Processing gaps and unresolved records are shown separately when the available evidence does not support a defensible dollar amount.
Contract opportunity · shown separately
$50,000 estimated annual difference to the selected benchmark
Humana ($36,500) and Oscar ($13,500) appear to pay according to their terms, but the reimbursement level in those terms is materially below the practice’s 110% of Medicare target. This is a contract-performance comparison, not a recoverable payment variance, and it is not included in the $219,225 above.
Where the quantified differences are concentrated
Where are the financial differences concentrated?
Payers ranked by total identified variance. UHC’s figure is mostly unreconciled payments; Curative’s is contract pricing; Medicare and Texas Medicaid are small because fee-schedule pricing leaves little room for variance.
| Payer | Lines reviewed | Contract variance | Payment variance | Other quantified | Total identified |
|---|---|---|---|---|---|
| All | 68,914 | $128,640 | $61,215 | $29,370 | $219,225 |
The three payers with the most identified variance — UHC, Curative and BCBS TX — account for 63% of the total but only 39% of the lines reviewed. The final column is the only one that should drive priorities.
Processing gaps
Where did the financial path stop before we could fully reconcile it?
Each row is a stage where the next expected record was not found. Counts come first; a dollar amount appears only where the available evidence supports one. Gaps are unresolved, not negative — most close with a single retrieved source.
| Gap | Records | Quantified amount | Source that would resolve it | Status |
|---|---|---|---|---|
| All gaps | 164 | $29,370 quantified | 110 records carry no amount until the payer disposition is known | |
The $29,370 quantified here is the “other quantified revenue gaps” figure on page one. The unquantified records are not added to any total.
Representative findings
What does one of these findings actually look like?
Four findings from four different classes. Each shows the comparison, why Britepath believes it, and the evidence available to verify it. Every number traces to a source document.
Example A — contract variance
Claim 71880 · CPT 99213-25
Why
Curative contract, version 2026 · Rule: Evaluation & Management, 99201–99499 · 115% of the applicable Medicare allowable ($108.24, locality 31) · DOS-specific fee schedule (CMS PFS 2026) · Lesser-of rule applied — billed $209.00 exceeds the calculated rate
Evidence available
Claim · EOB / ERA 2026-09-02 · Contract provision (Exhibit A §1.2) · Fee-schedule rate
Example B — payment variance
Claim 80421 · CPT 11750
Why
The remittance (ERA 2026-09-01) establishes payer responsibility of $126.00 and cites trace 0091827733, but no matching payer receipt or posting was identified in the available payment records.
Evidence available
Claim · ERA / remittance · Payment-posting history · Matching logic
Example C — processing gap
Claim 91011 · 4 submitted service lines
Why
One submitted service line has no matched adjudication record in ERA 2026-09-04. More evidence is required before a financial amount can be assigned.
Evidence available
Claim · 837P submission · ERA 2026-09-04 · 277CA acceptance
Example D — payment variance, posting
Claim 77512 · 3 surgical lines
Why
The remittance reports $2,410.00 paid on one EFT. Postings matched to this claim total $1,568.00; the remaining $842.00 of the same EFT is posted to a different patient account. This is most likely a posting problem rather than payer nonpayment.
Evidence available
Claim · ERA 2026-08-27 · EFT #BC77120 · Posting ledger
Example C shows the discipline behind the headline figure: when a submitted line has no adjudication, Britepath reports the gap and the missing source instead of estimating a value.
Contract performance
Are we losing money because the payer is wrong, or because the contract itself is weak?
This page separates the negotiation problem from the revenue-integrity findings. Realized reimbursement is payer allowed ÷ Medicare allowable across the lines reviewed; the practice target is 110% of Medicare.
Humana · Gold Plus (MA)
| Actual annualized allowed | $107,000 |
| Medicare-equivalent reimbursement | 82% |
| Selected target | 110% |
| Estimated annual difference to target | $36,500 |
|---|
The payer appears largely consistent with the contract. The larger issue is the reimbursement level in the agreement itself.
Oscar · Bronze / Silver
| Actual annualized allowed | $33,800 |
| Medicare-equivalent reimbursement | 71.4% |
| Selected target | 100% |
| Estimated annual difference to target | $13,500 |
|---|
No Oscar agreement was provided, so compliance cannot be evaluated. The observed level is a benchmark only; loading the contract would make every Oscar line evaluable.
Payers ranked by realized reimbursement
Best to worst on payer allowed ÷ Medicare allowable, with how much of the expected payment each payer actually delivered and how long it took.
| # | Payer | Realized Medicare equivalent | Collected | Days to pay | Annual allowed | Contract variance identified |
|---|---|---|---|---|---|---|
Methodology
How did Britepath determine what happened?
We reconstruct the available financial history at the claim and service-line level. Depending on the available data, we identify the date of service, payer and plan, procedure code, modifiers, provider and location, claim-submission history, payer adjudication, allowed amount, adjustments, patient responsibility, remittance, payer payment, payment posting, and balance activity.
Where contract analysis is possible, we select the contract and fee-schedule version effective on the date of service, calculate the applicable contractual allowable, apply the relevant pricing rules, and compare that calculation with the payer adjudication. We then reconcile the payer’s stated financial responsibility with the payment evidence available to the practice. When a required source is missing or ambiguous, the record remains unresolved rather than being converted into a confident financial finding.
Terms used in this report
- Payer allowed
- Source fact from adjudication.
- Contract-calculated allowable
- Britepath calculation from the applicable contract rule.
- Expected payer payment
- Amount the available adjudication indicates the payer is responsible for after supported patient responsibility and adjustments.
- Matched payer payment
- Payer receipt or posting that Britepath can associate with the claim or service line.
- Benchmark
- Comparison value such as Medicare.
- Potential contract variance
- Contract-calculated allowable minus payer allowed, after applicable rules.
- Potential payment variance
- Expected payer payment minus matched payer payment, after supported offsets and reconciliation rules.
- Processing gap
- Expected financial event or record not found in the next stage.
- Contract opportunity
- Modeled difference to a selected contract benchmark or scenario.
Review states
Every finding carries one of eight review states: Unreviewed, Needs review, Validated, Pursued, Waiting on payer, Recovered, Closed — no recovery, Resolved — no issue. In this audit, $71,340 of the identified figure has been validated by a reviewer; nothing has been marked recovered. No confidence percentages or recovery scores are used.
What happens next
We pursue validated recovery opportunities
Britepath can work from validated findings and track recovery activity from the original claim through any additional remittance or payment received. Each recovery is attributed to the specific claim, remittance and payment that produced it, so the practice can verify every dollar invoiced.
Commercial terms are set in the engagement agreement.
Recommended first steps
- Reconcile the UHC payments ($31,840). Twelve adjudicated claims have payer responsibility with no matched payment. A payment trace request to UHC resolves most of them.
- Request reprocessing from Curative ($28,419). 43 validated E&M lines are allowed below the 115% of Medicare rule in Exhibit A §1.2.
- Run a claim-status batch on the 84 unadjudicated claims. No amount can be assigned until the payer disposition is known; 22 are older than 45 days.
- Provide the Oscar agreement. 1,910 lines become evaluable; today they can only be benchmarked.
- Model a Humana proposal. The agreement pays 82% of Medicare on $107,000 of annual allowed; the negotiation, not the payer, is the lever.