Book a call ↗What the written report looks like after a free audit call, shown for Northfield Family Medicine, a fictional practice.
Every name, encounter ID and figure on this page is made up. The figures show how the report is laid out. They don’t describe any real practice, and they aren’t results Highview has achieved.
A real report uses your own billing data, reviewed under a signed business associate agreement (BAA), and covers the areas agreed on the free audit call.
Every claim billed in the period, by where it stands today.
| Status | Claims | Billed charges | Open balance |
|---|---|---|---|
| Paid in full | 6,877 | $1,472,602 | $0 |
| Paid, patient balance due | 424 | $89,627 | $28,950 |
| Open with insurer | 618 | $130,605 | $130,605 |
| Denied, not yet resolved | 141 | $31,061 | $31,061 |
| Total | 8,060 | $1,723,895 | $190,616 |
Open balances are shown at billed charges. What a payer allows is usually lower. Visits that were never billed aren’t claims yet; they’re in section 5.
The open balance from section 1, split three ways so it’s clear what needs follow-up: recent insurer claims, older insurer balances, and what patients owe.
| Age | Claims | Balance at billed charges | No payer acknowledgement | Already denied |
|---|---|---|---|---|
| 0–45 days | 561 | $119,159 | 55 | 22 |
What needs follow-up: Most of these are within normal payer processing time and need no action yet. Follow up now on the 55 with no payer acknowledgement and the 22 already denied.
| Age band | Claims | Balance at billed charges | Of which denied | Next step |
|---|---|---|---|---|
| 46–90 days | 55 | $11,287 | 30 | Past typical payer processing time. Check each claim’s status and work any denials. |
| 91–180 days | 62 | $13,664 | 43 | Needs a status check and, where a claim was denied, a corrected claim or an appeal. |
| 181–365 days | 81 | $17,556 | 46 | Check each claim against the payer’s filing limit first; some may no longer be collectible. |
| Total | 198 | $42,507 | 119 |
What needs follow-up: 66 of these claims are already past the payer’s filing limit. They stay in the bands above so the totals reconcile, but they may not be collectible unless there is proof the claim was filed in time.
| Age | Claims | Patient balance |
|---|---|---|
| 0–45 days | 63 | $4,815 |
| Over 45 days | 361 | $24,135 |
| Total | 424 | $28,950 |
What needs follow-up: Copays, coinsurance and deductibles the insurer has already processed. These are collected through patient statements, not payer follow-up, so they are kept separate.
Insurer claims that still need a clean claim on file, with 30 days or fewer left before the payer’s filing limit. These are worked first.
| Payer | Filing limit used (days) | Claims | Billed charges |
|---|---|---|---|
| Medicare | 365 | 3 | $430 |
| Medicaid plan A | 180 | 2 | $555 |
| Commercial payer A | 90 | 5 | $985 |
| Commercial payer B | 180 | 3 | $640 |
| Total | 13 | $2,610 |
| Encounter | Payer | Issue | Days since visit | Filing limit | Days remaining | Charge |
|---|---|---|---|---|---|---|
| S-006373 | Commercial payer A | Not on file with payer | 82 | 90 | 8 | $160 |
| S-006401 | Commercial payer A | Not on file with payer | 81 | 90 | 9 | $160 |
| S-000234 | Medicare | Not on file with payer | 354 | 365 | 11 | $110 |
| S-004504 | Medicaid plan A | Denied: missing or invalid information | 165 | 180 | 15 | $265 |
| S-004508 | Commercial payer B | Denied: eligibility or coverage | 165 | 180 | 15 | $160 |
| S-004543 | Commercial payer B | Denied: eligibility or coverage | 164 | 180 | 16 | $235 |
| S-004547 | Commercial payer B | Not on file with payer | 163 | 180 | 17 | $245 |
| S-006627 | Commercial payer A | Denied: missing or invalid information | 72 | 90 | 18 | $160 |
| S-000433 | Medicare | Not on file with payer | 346 | 365 | 19 | $160 |
| S-006695 | Commercial payer A | Not on file with payer | 68 | 90 | 22 | $270 |
Filing limits vary by payer and by contract. The limits here are illustrative; a real report uses the limits in the practice’s own payer contracts.
Denied claims not yet resolved, grouped by the reason the payer gave. Patterns point to fixes upstream, at registration, authorization or charge entry.
| Reason | CARC | Claims | Billed charges | Next step |
|---|---|---|---|---|
| Missing or invalid information | 16 | 42 | $9,071 | Correct the claim and resubmit. |
| Eligibility or coverage | 27 | 28 | $6,381 | Verify coverage and bill the right payer. |
| Bundling (included in another service) | 97 | 21 | $4,663 | Check whether a modifier is supported; if not, write off. |
| Prior authorization missing | 197 | 19 | $4,368 | Look for an authorization on file; appeal if one exists. |
| Medical necessity | 50 | 18 | $3,633 | Review documentation and diagnosis coding before appealing. |
| Duplicate claim | 18 | 7 | $1,578 | Confirm the original was paid; usually no action. |
| Timely filing | 29 | 6 | $1,367 | Appeal only with proof of timely submission. |
| Total | 141 | $31,061 |
CARC is the standard claim adjustment reason code on the payer’s remittance. Each category shows the most common code.
Visits in the schedule with no claim sent: 117 visits, $24,432 in charges at the practice’s own rates.
| Reason | Visits | Older than 14 days | Charges |
|---|---|---|---|
| Visit note not yet signed | 63 | 53 | $13,341 |
| Charge not entered | 38 | 37 | $7,555 |
| Held for missing insurance details | 16 | 16 | $3,536 |
| Total | 117 | 106 | $24,432 |
Visits from the last two weeks are often still being documented. Older unbilled visits need a decision: bill them before the payer’s filing limit, or record why they won’t be billed.
12 office visits reviewed against their documentation: 5 billed above what the documentation supports, 2 billed below it, and 5 that match.
| Encounter | Provider | Code billed | Documentation supports | Direction | Finding |
|---|---|---|---|---|---|
| S-004269 | Provider C | 99214 | 99213 | Above documentation | Decision-making documented as low, not moderate. |
| S-004500 | Provider B | 99214 | 99213 | Above documentation | Decision-making documented as moderate, not high. |
| S-004734 | Provider A | 99213 | 99213 | Matches | Documentation supports the code billed. |
| S-005392 | Provider C | 99213 | 99213 | Matches | Documentation supports the code billed. |
| S-005462 | Provider A | 99214 | 99213 | Above documentation | Decision-making documented as low, not moderate. |
| S-005481 | Provider C | 99214 | 99214 | Matches | Documentation supports the code billed. |
| S-005662 | Provider B | 99214 | 99213 | Above documentation | Total time documented falls short of the billed level. |
| S-006378 | Provider B | 99214 | 99213 | Above documentation | Decision-making documented as moderate, not high. |
| S-006532 | Provider B | 99213 | 99213 | Matches | Documentation supports the code billed. |
| S-006544 | Provider C | 99213 | 99214 | Below documentation | Total time documented supports the higher level. |
| S-006596 | Provider B | 99214 | 99214 | Matches | Documentation supports the code billed. |
| S-006623 | Provider B | 99213 | 99214 | Below documentation | Total time documented supports the higher level. |
Over-coding carries a repayment obligation. Where the documentation supports a lower code than was billed, the practice may have been paid more than it was owed and may have a repayment obligation to the payer. The report flags these for correction just as clearly as visits billed below the documentation.
A small sample shows the format. It is not a coding error rate.
Enrollment status with each payer, for the practice as a group and for each provider individually.
| Payer | Group (practice) | Provider A | Provider B | Provider C | Next step |
|---|---|---|---|---|---|
| Medicare | Participating | Participating | Participating | Participating | No action needed. |
| Medicaid plan A | Not enrolled | Needs verification | Participating | Participating | Start enrollment before sending this payer claims for anyone not enrolled. |
| Medicaid plan B | Participating | Participating | Needs verification | Participating | Confirm status with the payer before the next claims go out. |
| Commercial payer A | Needs verification | Not enrolled | Participating | Participating | Start enrollment before sending this payer claims for anyone not enrolled. |
| Commercial payer B | Not enrolled | Participating | Participating | Participating | Start enrollment before sending this payer claims for anyone not enrolled. |
| Commercial payer C | Participating | Participating | Participating | Participating | No action needed. |
Group enrollment and each provider’s individual enrollment are checked separately: a practice can be in network while one of its providers is not.
A conversation is the first step toward the right support.