What we do, in the order it happens.
Six stages, from the patient's first call to the last appeal. For each one: what goes wrong, what we do, what Rook does, and what stays outside our control.
Request a revenue assessmentRook was trained across all of our clients and all specialties. Today it is in full use at one practice.
Prevent
Patient access
What goes wrong
The follow-up visit is booked off the first verification. The authorization has expired, the visit limit is reached or the plan changed mid-year, and nobody finds out until the claim comes back unpaid.
What we do
Benefits verified by phone with the carrier, on a template built with the practice. Authorizations requested with the clinical documentation, recorded, and tracked to expiration.
What Rook does
The benefit verification and authorization process runs in the workbench. The office-specific patient journey is in build.
Outside our control
Benefits are the payer's information on the day of the call. The payer decides medical necessity.
Revenue integrity
What goes wrong
The service was performed, and the documentation does not support the code that was billed. Most coding errors start as a documentation or workflow habit.
What we do
Chart audits by a Certified Professional Medical Auditor, before billing or on a sample afterward. Pre-bill review of CPT, ICD-10-CM and HCPCS coding. Coding education and training for providers and staff.
Outside our control
Findings reflect the documentation available at review. Final code assignment stays with the practice and the treating provider.
Detect
Claims and payment
What goes wrong
A claim goes out clean in format and wrong in content. A payment comes back short and is posted as if it were right.
What we do
Claims scrubbed before submission against payer edits, NCCI, MUE and coverage policy. Payments posted and reconciled to the deposit and to expected reimbursement. Underpayments routed to follow-up, not written off.
What Rook does
Receives each electronic remittance and parses it line by line.
Outside our control
Final reimbursement is determined by the payer.
Denial intelligence
What goes wrong
A line that paid zero is treated as a denial and appealed, though it was never appealable. A true denial waits in a queue while its filing window runs.
What we do
Every denial categorized by what its reason code means, traced to its cause, and reported back to the practice as a trend.
What Rook does
Triages each line, separates the denials from the adjustments, and routes each denial by reason code and line of business. What expires first goes first.
Recover
Appeals and recovery
What goes wrong
A generic appeal letter answers a point the carrier never made. It is denied again, with less time left.
What we do
Appeals written in the payer's own policy language, with citations to the carrier's published medical policy, the LCD or NCD, NCCI logic or state regulation. External review and state insurance department complaints where warranted. Underpayment and out-of-network recovery. ERISA and state health benefit appeals.
What Rook does
Pulls the authorized-representative form and the record, reads the record, drafts the argument, and sends the package to the carrier by portal, mail or fax.
Outside our control
The determination belongs to the payer or the reviewer. No outcome is guaranteed.
Dispute resolution
What goes wrong
The dispute is no longer about the code. It is about how the policy and the regulation are read.
What we do
New Jersey PIP arbitration prepared and followed up. Workers' compensation fee schedule disputes and litigation files, prepared with counsel. Files for federal No Surprises Act IDR and, separately, for state out-of-network arbitration. Direct negotiation on high-dollar claims. Responses to RAC, UPIC and commercial audits.
Outside our control
The arbitrator, the court or the IDR entity decides. We work in a non-attorney capacity, in coordination with the client's counsel.
LearnWhat each denial teaches goes back to the first call: as a rule in Rook, as a change at the front desk, as training for the provider.