Case Studies

Real Results from Real Practices

Detailed before-and-after analysis from healthcare organizations that deployed NexaClaim AI and measured the impact on their revenue cycle.

$5.1M

Revenue recovered across 3 case studies

11 days

Average time to deployment

77%

Average denial rate reduction

Orthopedic SurgerySoutheast US150-physician groupLive in 11 days

$2.8M recovered in 90 days, denial rate dropped from 9.2% to 2.8%

The Challenge

One of the largest orthopedic groups in the Southeast was hemorrhaging revenue from a 9.2% denial rate — nearly double the national benchmark for orthopedics. Their RCM team of 14 was overwhelmed: only 31% of denials were being appealed, and the team had no systematic way to prioritize which cases to fight first. Prior authorization denials had doubled year-over-year as their largest MA payer expanded PA requirements to include routine arthroscopic procedures.

9.2% denial rate vs. 4.7% national benchmark for orthopedics
$4.1M in denials annually — $2.8M estimated recoverable
Only 31% appeal rate due to team bandwidth constraints
Prior auth denials up 103% YoY from Medicare Advantage expansion
No payer-specific appeal templates — average letter took 2.5 hours to write

The Solution

NexaClaim was deployed in 11 days with a focus on three modules: denial triage and prioritization, AI appeal letter generation, and prior authorization pre-screening. The implementation team configured payer-specific denial playbooks for the group's top 8 payers by volume, pre-loaded 3 years of historical denial data to train the recovery probability models, and integrated with their existing billing system via SFTP file exchange.

Denial Triage AI — automatic priority scoring on every new denial

Appeal Letter Generator — payer-specific templates for top 15 denial reason codes

Prior Auth Pre-Screener — flags procedures requiring MA authorization before scheduling

Recovery Dashboard — real-time view of appeal status and revenue recovery

The Results

Denial Rate

Before

9.2%

After

2.8%

-70%

Appeal Rate

Before

31%

After

89%

+187%

Appeal Win Rate

Before

52%

After

79%

+52%

Revenue Recovered (90 days)

Before

After

$2.8M

New

Time per Appeal Letter

Before

2.5 hrs

After

18 min

-88%

PA Denial Rate

Before

14.7%

After

3.1%

-79%

“
We went live in under two weeks and saw our first recovered denial within 72 hours. The AI appeal letters are genuinely impressive — they cite the exact UHC coverage policy language that our payer rep told us in a peer-to-peer. Our team went from dreading the denial queue to actually feeling like they have a fighting chance.
VP of Revenue Cycle
150-Physician Orthopedic Group, Southeast US

Ambulatory Surgery CentersTexas12-facility networkLive in 14 days

Coding time dropped from 38 min to 9 min, first-pass rate climbed to 96%, $1.4M in coding errors prevented

The Challenge

A 12-facility ASC network in Texas was facing compounding revenue cycle pressures: coding accuracy issues were driving up denial rates, and a shortage of certified coders was slowing encounter processing by 3–4 days. First-pass claim acceptance rate had declined from 91% to 83% over 18 months. The CFO had been told by their legacy billing vendor that "AI coding is not ready for complex ASC procedures" — but was skeptical after seeing peers report strong results.

First-pass claim acceptance rate declined from 91% to 83%
Average coding time of 38 minutes per encounter — coder shortage worsening
Estimated $1.4M in preventable coding-error denials annually
3–4 day billing lag from encounter to claim submission
Coder turnover rate of 34% annually due to burnout

The Solution

NexaClaim was deployed across all 12 facilities in 14 days with the AI Coding Assistant as the primary module. The system was fine-tuned on 8,000 historical ASC encounters across the network's top surgical specialties (orthopedics, GI, ophthalmology, pain management). A confidence threshold of 0.88 was set for auto-approval, with mandatory human review for add-on codes and high-value procedures above $15,000.

AI Coding Assistant — fine-tuned on ASC-specific procedure documentation

Bundling Conflict Detector — real-time flag for CCI bundle violations

Modifier Advisor — context-aware modifier recommendations (59, 25, 57, RT/LT)

Payer Rule Engine — 847 payer-specific coding rules pre-loaded at go-live

The Results

Coding Time per Encounter

Before

38 min

After

9 min

-76%

First-Pass Claim Rate

Before

83%

After

96%

+13pp

Coding-Error Denials (Annual)

Before

$1.4M

After

$180K

-87%

Claim Submission Lag

Before

3.8 days

After

0.9 days

-76%

Coder Cases per Day

Before

After

+242%

Net Revenue Impact

Before

Baseline

After

+$2.1M/yr

New

“
The AI handles the straightforward cases — and there are a lot of them — so our coders can focus on the complex multi-procedure cases that actually need their expertise. Our best coder told me she feels like she finally has the right tool for the job. Turnover has dropped because the job is actually enjoyable again.
CFO
12-Facility ASC Network, Texas

OncologyRegional (Mountain West)45-physician practiceLive in 9 days

PA turnaround from 12 days to 1.8 days, 40 hours/week of staff time freed, $890K in revenue unlocked

The Challenge

A 45-physician regional oncology practice was being strangled by prior authorization delays. With an average PA turnaround of 12 days — and some payers regularly exceeding 3 weeks — treatment delays were becoming a patient safety issue, not just a financial one. The practice's PA team of 6 was spending 85% of their time on manual phone calls and portal navigation. With oncology-specific drugs requiring auth for every cycle, the volume was unsustainable.

Average PA turnaround of 12 days (payer range: 4–22 days)
40 hours per week of staff time consumed by manual PA processes
Treatment delays affecting an estimated 28% of patients monthly
$890K annually in revenue tied up in pending or denied authorizations
PA denial rate of 18.3% — highest the practice had ever recorded

The Solution

NexaClaim was deployed in 9 days with Prior Authorization Automation as the primary module. The system integrated with the practice's EHR via SFTP clinical document extraction and configured payer-specific criteria mapping for the top 12 oncology drugs and 28 procedure types. Automated peer-to-peer request triggers were configured for all initial denials, and the system was set to escalate to the IRE pathway for MA plan denials exceeding 5 days.

PA Automation Engine — auto-submit requests with clinical criteria pre-matched

Drug Auth Tracker — real-time status across 12 payer portals

Peer-to-Peer Prep Brief — AI-generated clinical argument for physician review calls

Denial Escalation Workflow — automatic IRE/external review triggers for MA plans

The Results

PA Turnaround (avg)

Before

12 days

After

1.8 days

-85%

Staff Time on PA (weekly)

Before

40 hrs

After

6 hrs

-85%

PA Denial Rate

Before

18.3%

After

4.2%

-77%

Revenue from Faster Approvals

Before

Baseline

After

+$890K/yr

New

Treatment Delay Rate

Before

28%

After

-86%

Physician PA Time (weekly)

Before

9 hrs

After

1.5 hrs

-83%

“
Prior authorization delays in oncology are not just a billing problem — they affect patient outcomes. Getting a chemotherapy approval in 1.8 days instead of 12 days is clinically significant. NexaClaim solved what we thought was an unsolvable problem in 9 days of deployment.
Medical Director of Oncology
45-Physician Oncology Practice, Mountain West

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Average deployment: 11 days. No EHR integration required for pilot.