We run medical coding, billing, prior authorization, eligibility verification, denial management, and patient access for US hospitals, providers, dental groups, and telehealth platforms. HIPAA aligned. Dedicated US time zone pods. 50 to 60% lower than US in house.
Coders and billers leaving the industry, denials eating cash flow, and prior auth mandates compressing timelines. The same three failure modes show up in every CFO and revenue cycle review.
Turnover in billing departments runs above 22% annually. Certified coders command $55K to $90K starting salaries, often more for CPC certified. BLS projects 8% role growth through 2030 against vacancies already at record highs. Each empty seat becomes coding errors, claim delays, and revenue leak.
US hospitals lose around $262B annually to claim denials. Most are preventable through accurate coding, eligibility verification, and timely resubmission. The work that prevents them is exactly the work in shortest staffing supply.
New 2026 prior auth mandates compress payer turnaround windows. In house teams are already swamped. Patients wait, scheduling slips, and patient experience scores tied to admin operations slide with them.
Same operating model whether you are a 200 bed community hospital, a 50 location MSO, a DSO, or a national telehealth platform. Volumes, specialties, and EHRs change. The build does not.
Specialty mix, volumes by workstream, payer mix, EHR/PM, KPIs (denial rate, A/R days, clean claim rate). 30 minute working session, signed scope on paper.
Dedicated pod assembled from background checked, HIPAA trained, certified staff. Trained on your EHR, your specialties, your QA standards. Account lead assigned. BAA + DPA signed.
Daily output against SLA. Weekly QA sampling against your standards. Monthly business review against signed KPIs (denial rate, A/R days, clean claim rate, productivity).
Capacity scales 3 to 5x in 14 days for volume ramps, M&A integrations, EHR cutovers, or seasonal spikes. Same QA standards, same account lead.
The revenue cycle and patient access work that drives cash flow, denial rate, and patient experience scores. Run end to end or as targeted lift outs by workstream.
CPC, CCS, CCS-P certified coding across CPT, ICD-10-CM, HCPCS. Inpatient, outpatient, profee, ED. Specialty trained pods.
Claim submission, payment posting, A/R follow up, secondary billing, refund processing. Cash velocity is the metric we sign up to.
24/7 prior auth submission, status follow up, peer to peer scheduling. Payer rules updated weekly. SLA on submission and follow up.
Real time benefit verification, coverage discovery, secondary insurance identification, patient responsibility estimation.
Root cause analysis, appeals drafting, payer follow up, denial trend reporting back to coding. 30 to 40% denial reduction is the standard.
Scheduling, registration, pre registration, point of service collection, prior auth coordination. Where revenue cycle starts.
Inbound and outbound patient support, billing inquiries, payment plans, statement questions. 24/7 and bilingual.
Clinical Documentation Improvement query workflow, HCC capture, risk adjustment support, MIPS and quality measure tracking.
Shared offshore RCM BPO is cheap but generic. Dedicated pods cost a touch more, but they learn your EHR, your specialty mix, and your payer rules instead of starting from zero each shift.
Use shared BPO for the easy 60 to 70% of generic coding. Use us where the work needs your specialty rules and your payer mix.
EHR/PM agnostic, certified, US time zone overlap, HIPAA aligned by default.
Epic, Cerner, Athena, Allscripts, NextGen, eClinicalWorks, Practice Fusion, Greenway, Centricity, Meditech, AS/400 legacy.
When an engagement requires certified coders (CPC, CCS, CCS-P, CIC, COC), we recruit and onboard certified hires for the pod. Specialty training (cardiology, ortho, oncology, behavioral health, dental) per engagement.
Multi region delivery (Luzon, Florida, Colombia, Indonesia, Malaysia, Vietnam) means genuine 24/7 with US time zone overlap on demand.
English and Spanish at no premium. Tagalog, Mandarin, Bahasa, Vietnamese, Portuguese, French on request.
Sampled QA every week against your standards. Full business review every month against signed KPIs (denial rate, A/R days, clean claim rate).
Every engagement has an Arbitrail account lead who owns delivery end to end. One name, one number, one source of truth.
HIPAA training completed before first encounter is touched. Annual refresh. BAA signed before any PHI is accessed.
We work inside your EHR on read only credentials wherever workflows allow. Edit access is documented and audited.
Patients see your brand on calls, emails, statements, and follow ups. Co branded mode available if you prefer.
The operational practices and controls that ship by default with every engagement. Pragmatic, documented, and contractually committed.
Three structural reasons US providers, hospitals, MSOs, DSOs, and telehealth platforms run with us instead of a generic shared RCM BPO or stitched subcontractor stack.
Shared pools rotate staff, learn nothing, and start from zero each shift. Dedicated pods learn your specialty mix, your payer rules, and your QA standards in week one and compound from there. Coding accuracy and denial rate both bend in your favour.
A generic coder is a denied claim. When an engagement requires certified coders (CPC, CCS, CCS-P), we recruit by specialty: cardiology, ortho, oncology, behavioral health, dental, plus profee, inpatient, and outpatient. Your specialty mix sets the pod composition.
Multi region delivery (Luzon, Florida, Colombia, Indonesia, Malaysia, Vietnam) for genuine 24/7 with US overlap. 50 to 60% lower than US in house. One Arbitrail SG contract instead of stitching three vendors. Account lead per engagement.
US hospitals lose around $262 billion annually to claim denials. Most are preventable. Yet the average hospital denial rate has climbed from roughly 9% in 2016 to over 12% in 2024, and continues to creep up. The carriers and providers who reverse this trend do not do it with a single fix. They do it with a sequenced playbook that attacks the denial sources in the right order, with the right people, against KPIs they actually measure weekly.
Every denial fits into one of five root-cause categories. Knowing which category dominates your specific mix is the first step. Prioritization matters because the categories have very different fix profiles.
Around 25 to 30% of all denials trace back to eligibility verification gaps and missing or expired prior authorizations. These are the cheapest to prevent because they happen before the encounter or before claim submission. A disciplined patient access workflow with real-time eligibility verification and prior-auth status tracking can eliminate most of this category.
Around 20 to 25% of denials are coding-driven: wrong CPT, wrong ICD-10-CM, wrong modifier, missing diagnosis specificity, mismatched DRG. The fix is upstream: certified coders working from accurate clinical documentation, with weekly QA sampling against AHIMA or AAPC standards. Coding accuracy under 95% is a reliable signal that this bucket is your biggest opportunity.
Around 15 to 20% of denials cite medical necessity. The fix is partly clinical (CDI program with physician engagement) and partly process (documentation completeness checks before claim submission). Hardest to fix without provider buy-in.
Around 10 to 15% of denials are administrative: late filing, duplicate submission, missing data field. These are the cheapest of all to fix and the most embarrassing to lose. Process discipline alone resolves most of this bucket.
The remainder is payer-policy specific: bundling rules, NCCI edits, payer-specific exclusions. The fix is a payer-rules engine that updates weekly and a coder team trained on the top three payers’ specific rules. This is where dedicated specialty pods materially outperform generic shared BPO services.
Industry-average coding accuracy sits at 92 to 95% (across hospital and physician coding combined). Specialty-trained certified coders working with weekly QA against your specific specialty mix consistently hit 96 to 98%. That three-to-four-point gap is enormous: at typical claim volumes, every percentage point of first-pass accuracy is worth roughly $1.5M to $4M in annual collected revenue depending on hospital size.
The discipline that closes the gap is not a single tool. It is a combination of: specialty-specific coder training (cardiology coders coding cardiology, not generic), weekly QA sampling with feedback loops to the coder team, monthly business reviews against denial-rate KPIs, and tight loop-back from the denial team to the coder team so the same error pattern is not repeated. Generic shared-pool BPO models break down on every one of these dimensions.
Real-time eligibility verification is the single highest-ROI investment a revenue cycle leader can make. The math is simple: a denial discovered post-submission costs $25 to $118 per claim to work down (the AHIMA estimate). The same denial caught before submission costs effectively zero. At a typical 1,000-claim-per-day hospital with a 12% denial rate, the cost differential between catching and not catching denials at eligibility verification is in the millions annually.
The implementation that actually works: real-time benefit verification at scheduling (not at registration), coverage discovery for self-pay claims, secondary insurance identification, and patient responsibility estimation that hits the patient’s phone before they show up. Fragmented or delayed eligibility verification is the most common implementation gap in mid-market hospitals.
The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) effective January 2026 has materially changed the prior-auth landscape. Payers must now respond to expedited prior auth requests within 72 hours and standard requests within 7 days. They must publish prior-auth metrics annually. They must provide automated payer-to-provider data exchange via FHIR APIs by January 2027.
Two implications for revenue cycle. First, the response window has compressed; in-house teams that previously managed prior auth at end-of-day or end-of-week now need real-time processing capacity. Second, the data flow is becoming machine-readable, which means payer rules can be encoded into a rules engine and applied at the point of service rather than requiring a human reviewer for every case. Carriers and BPOs that implement against the new rule earn a material capacity advantage. Carriers and BPOs that ignore it run face-first into the compliance and the cycle-time pressure.
Expedited requests: 72-hour response. Standard requests: 7 days. Annual public metrics required. FHIR API mandate by Jan 2027. The Rule applies to Medicare Advantage, Medicaid managed care, CHIP managed care, and ACA marketplace QHPs.
Around 65% of hospital denials are never appealed. Of the 35% that are, 63% are successfully overturned. The math is brutal: hospitals are leaving roughly $200B in revenue on the table because they do not appeal. The fix is not heroic effort, it is a structured appeals workflow.
The structure that works: denials triaged by appeal-likelihood within 48 hours of receipt (not all denials are worth appealing; the 80/20 matters here), appeals drafted from a template library by payer and denial reason rather than written from scratch, tracking against payer-specific deadlines (each payer has its own appeal window, often 60 to 180 days), and feedback to coding when an appeal succeeds because of a coding fix so the same error does not repeat. A well-run appeals operation overturns 60 to 70% of attempted appeals.
Most denial-reduction programs fail because they measure the wrong things. Three KPIs are non-negotiable.
First-pass clean claim rate, measured weekly. The percentage of claims that pay on first submission without any rework. Industry average sits around 80 to 85%. Best-in-class is 96%+. This is the leading indicator that everything upstream is working.
Denial rate by category, measured monthly. Total denials over total claims, broken into the five categories above. The trend by category over six months tells you whether your interventions are working. Aggregate denial rate alone is too lagging and too lossy.
Days in A/R, measured weekly. Total accounts receivable divided by average daily charges. Industry average sits at 45 to 55 days. Best-in-class is under 35. Days in A/R captures both the upstream (clean claim rate) and downstream (collections velocity) of the cycle, so it is the single best summary metric.
Arbitrail’s Healthcare BPO pods are structured around this exact playbook. Specialty-trained certified coders, real-time eligibility verification, 24/7 prior-auth queue management against the 2026 mandates, structured appeals workflow with payer-specific templates, weekly QA sampling, monthly business review against the three KPIs above. Engagements typically deliver a 30 to 40 percent denial reduction within 90 days.
Bring your specialty mix, your highest friction workstream (likely coding, denials, or prior auth), and the KPIs you commit to your CFO. We scope a POC against your KPIs in 30 minutes, run it for 15 days, and walk if we miss.
What providers, hospitals, MSOs, DSOs, and telehealth platforms ask before bringing Arbitrail in. Anything else, just email and we will answer the same day.
Send a message about Arbitrail Healthcare, book a discovery call, or email us directly. We reply within 24 hours, weekdays.
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Open CalendlyBring your specialty mix, your highest friction workstream, and the KPIs you commit to your CFO. We will scope a 15 day POC against your KPIs in 30 minutes.