How Practice OS works
One claim's journey through five integrated modules — under one login, on one dashboard. Predict the rate. Prevent the denial. Fight the denial. Recover the underpayment. Renegotiate the contract.
One pipeline. Every stage compounds the next.
Every stage feeds the next. Every signal compounds. The same TiC MRF rate database powers all five modules — so the prediction at Stage 1 is the same source of truth that wins the appeal at Stage 3 and the renegotiation at Stage 5.
Predict the rate before the claim is sent.
Before the claim ever goes out, ReimburseOS predicts what every payer is contractually obligated to pay for that CPT for that practice's tax ID.
Source: Transparency in Coverage MRF data published monthly by every commercial payer in the United States, mandated by the TiC Final Rule (effective July 2022).
At production scale this module ingests 200K+ claims/mo across 47 active practices in CA, NV, and AZ — illustrative production-state volume.
- CPT / HCPCS code
- Practice tax ID (TIN)
- Payer ID + plan
- Place-of-service · modifiers
- Geographic locality
- Expected $ amount per CPT
- Percentile vs MGMA + market
- Confidence score (0–100)
- Annual expected revenue
Catch the denial before it leaves the building.
Sentry OS scrubs every claim against NCCI bundling edits, modifier compatibility, LCD frequency limits, POS validity, payer-specific policy, and the rate signal from Stage 1.
If the predicted reimbursement is materially below the contracted rate, or if the claim will trigger a known denial code, Sentry kicks it back to the biller in under 200 ms — before submission.
At production scale: ~30% of submitted claims get a flag; ~12% get auto-corrected; $300K–$500K of A/R protected per practice/year — illustrative production-state volume.
- Outbound claim (837P / 837I)
- Predicted rate from Stage 1
- NCCI / MUE / LCD tables
- Payer-specific edit packs
- PASS / FLAG / FIX verdict
- Plain-English fix instruction
- Predicted denial code (if any)
- Re-submit-ready 837 file
Generate a legal-grade appeal in five minutes.
When a denial comes back — CO-97, CO-50, CO-16, PR-204 — Denial OS automatically classifies it, pulls the original claim, the Stage 1 predicted rate, the Stage 2 scrubber log, and generates a citation-grade appeal letter.
The contracted-rate paragraph is mandatory: every appeal cites the TiC MRF rate the payer published themselves. Industry baseline first-pass overturn is ~30%. With the rate paragraph, the demonstrated win rate climbs toward ~70%.
At production scale: ~5,200 appeals/mo, 5m04s median letter time, $0.20 cost per letter — illustrative production-state volume.
- 835 ERA / EOB denial
- CARC / RARC reason codes
- Stage 1 contracted-rate evidence
- Patient chart / SOAP note
- State + ERISA appeal rules
- Citation-grade appeal letter (PDF)
- TiC MRF contracted-rate paragraph
- Appeal deadline tracker
- Outcome ledger (overturned / upheld)
Sweep every paid claim that came in below contract.
Most underpayments hide in plain sight. The claim is "paid" — but it's paid below the rate the payer is contractually obligated to pay. Reclaim OS reconciles every 835 against the Stage 1 predicted rate and auto-flags every gap.
Each gap becomes a corrected-claim or a payer-letter, generated from the same TiC MRF evidence engine that powers Denial OS.
At production scale: ~$187K/practice/yr recovered from underpayment sweeps that legacy clearinghouses never surface — illustrative production-state volume.
- Every 835 ERA (paid claims)
- Stage 1 contracted-rate baseline
- Fee schedule + amendments
- Timely-filing windows
- Underpayment ledger (per claim)
- Auto-generated corrected claim
- Payer-by-payer underpayment heatmap
- Recovered-$ rollup for the dashboard
Walk into the renewal already holding the leverage.
When the contract renewal lands, Leverage OS produces a one-page negotiation memo: every CPT the payer underpaid, ranked by dollar gap; every TiC MRF rate the payer pays competing practices in the region; the volume the practice sends them; and the single clean ask for the next term.
Practices walk into renewals already holding the same data the payer's actuary has. 9% lift on a renegotiated contract is a typical Year-2 signal.
At production scale: ~$216K/practice/yr Year-2 lift on the next contract renewal cycle — illustrative production-state volume.
- 12-month payer scorecard
- Stage 4 underpayment ledger
- Stage 3 appeal-overturn rate
- Regional TiC MRF comp rates
- 1-page renewal leverage memo
- Per-CPT counter-rate proposal
- Walk-away threshold
- Year-2 expected-revenue model
The data foundation under all five products.
Every product taps the same insurer-mandated public rate database — Transparency in Coverage Final Rule (CMS-9915-F, effective July 2022).
Every commercial payer in the U.S. is required to publish, monthly, a Machine-Readable File (MRF) listing the negotiated in-network rate for every CPT code, for every contracted provider tax ID, for every plan they sell.
Every Practice OS module reads from this data backbone. There is no other generic AI billing tool doing this. The MRFs are terabytes of nested JSON published at midnight on the first of every month — they are not human-readable, not searchable, and not indexed.
We parse and normalize them.
One auth. One dashboard. One story.
The user signs in once to Practice OS. There are no five separate logins, no five passwords, no five vendors to call when something breaks. One identity, one tenant, one PHI boundary.
Every module reports into the same revenue cycle dashboard. Predicted revenue, scrubbed claims, appeals in flight, dollars recovered, upcoming renegotiations — every signal in one pane of glass.
There is no "Send to Denial OS" button — because Denial OS is the appeal-generator module within Practice OS. Cross-module data flow is automatic. The claim moves itself.
A generic AI billing tool sells you a feature. Practice OS sells you the cycle.
A scrubber-only vendor doesn't know what the payer's contracted rate is. An appeals-only vendor doesn't know which denials were preventable. A renegotiation consultant doesn't know which underpayments to use as evidence. Practice OS is the only product where Stage 1's prediction is the same source of truth that wins Stage 3's appeal and powers Stage 5's renegotiation memo.
Open the demo platform
Walk a single CPT through all five modules — Predict, Prevent, Fight, Recover, Renegotiate — under one login, on one dashboard, with no PHI.
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