Orthopedic Revenue Recovery

Your payers are keeping money your practice already earned. We find it.

ClaimPilot AI audits the claims your orthopedic practice has already submitted — every paid line checked against your contracted rates, every denial classified by reason and appeal deadline — and hands you a recovery report with appeals drafted for your approval. You pay only out of money actually recovered.

Start with a free sample audit Billing companies: partner with us

Free sample audit

Findings in 5 business days

Certified-coder review

BAA before data moves

Nothing filed without approval

The Problem

The anatomy of the leak

Your billing team is rightly focused on keeping current claims moving. So the backlog nobody has hours to work twice — the old money — quietly becomes write-offs. It isn't anyone's failure. It is arithmetic, and it leaks in three predictable places:

Leak One

Paid below contract

Payers pay less than the contracted rate on individual lines. Without a line-by-line comparison against your rate schedule, a small underpayment on a high-volume code repeats for months before anyone sees it — each occurrence too small to notice, the total anything but.

Leak Two

Denials aging out

Denied claims carry appeal deadlines. Every week a denial sits unworked, it moves closer to becoming unrecoverable — not because it wasn't owed, but because nobody had the hours to chase it. A denial that ages past its deadline is gone permanently, however strong the claim was.

Leak Three

Ortho-specific traps

Global-period overlaps, modifier 25/59/X usage, implant and hardware reimbursement — orthopedics has denial patterns general reviews aren't built to look for. That is where a specialist audit earns its keep, and where generic recovery vendors leave the hardest money behind.

Do the arithmetic on your own book.

A practice collecting $3M a year with just 2% in underpayments and unworked denials is leaving $60,000 a year on the table. At 5%, it's $150,000. (Illustrative math, not a projection — most practices have never measured their number.) The sample audit measures yours, on your own claims, for free.

The Engine

Built around how orthopedics actually bills

ClaimPilot works from the exports you already have — 837 claim files, 835 remittances, and your payer contract rate schedules. Every check below runs on every engagement; a general-purpose review runs almost none of them.

Line-by-line contract varianceEvery paid line compared against your contracted rate for that payer and code — not sampled, not spot-checked.
90-day global-period overlapsSurgical claims and the evaluation-and-management services inside their global windows, checked against global-period rules so bundled services aren't paid twice — or denied wrongly.
LateralityLeft/right and bilateral procedure lines reviewed for the laterality errors that quietly trigger denials and underpayments in ortho coding.
Modifier 25 / 59 / X usageSignificant, separately identifiable E/M services and distinct procedural services examined for correct modifier use — and for the denials that follow when payers bundle what should have been paid.
Implant & hardware linesImplant and hardware reimbursement patterns audited against what the contract actually allows — high-dollar lines where a single variance outweighs a month of small ones.
Denial classification & deadlinesEvery denial classified by reason code and appeal deadline, ranked by recoverable dollars and urgency, so the recoverable money is worked before the window closes.

Contract variance

When your rate schedule is on file, a finding is exact: the contracted amount, the amount actually paid, and the difference — with the contract itself as the evidence behind an appeal. This is the audit's strongest category, and the one we lead with.

Benchmark variance

When no contract rate is on file for a payer, findings run against a Medicare baseline and are labelled benchmark variance — a question to investigate, never claimed as an underpayment. Without the contract, we don't claim to know what was owed. That distinction is written into every report.

Discipline built into the engine

A line only flags when it was paid below the expected amount by more than a set tolerance — the greater of $1 or 2%. Correctly applied deductibles and trivial variances are deliberately left alone. Every finding is reviewed by a certified coder before delivery. A report you can put in front of a payer has to be right more than it has to be big.

How It Works

Three steps. No new software, no integration project.

You send what you already have

Recent claim and remittance exports (837/835 files) and your payer contract rate schedules. Data moves de-identified, or under a signed BAA over a secure transfer — never before one of those is in place.

We audit every line

Each paid claim is compared against the contracted rate; every denial is classified by reason code and appeal deadline. Findings are ranked by recoverable dollars — and a certified coder reviews every finding before it reaches you.

You approve everything

You receive a recovery report: each finding with the expected amount, the amount actually paid, and the evidence — with appeal letters drafted and ready for review. Nothing is submitted to a payer without your approval. Ever.

Terms

Contingency only. You pay out of recovered money — or not at all.

After the free sample audit, the service runs as a 90-day pilot on contingency. The terms are stated in full, in the open, before you send a single file:

20%

of verified recovered revenue — money actually collected, not findings on a report

$750/mo

floor per practice in any month the service is active

$10,000/mo

cap per practice — your cost is bounded in both directions

“Recovered,” defined: A payment counts only when it has been paid by the payer and posted, verified against your own remittance data, on a claim the audit flagged and worked, within a 180-day attribution window. If it isn't on an 835, it isn't billed.
Recoupment protection: If a payer later recoups a payment, the corresponding fee is credited back. You never keep paying for money you didn't keep.
Our bar: We aim to identify at least 10× the fee in credible recoverable revenue — findings the documentation supports, not wishful thinking. If the findings aren't there, the honest recommendation is not to continue.
What we don't do: We don't guarantee recoveries — payers decide appeals, and any vendor who promises otherwise isn't being straight with you. What we guarantee is the work.

See exactly what the free sample audit includes

The Founder

Built by the surgeon who lives with these claims

Jacob Duncan, DO

Board Certified Orthopedic Trauma Surgeon · Founder & CEO, ClaimPilot AI

Jacob Duncan, DO is a board certified orthopedic trauma surgeon and the founder of ClaimPilot AI. He built the company from the operating side of the specialty — from firsthand experience of how orthopedic practices lose revenue: contracted rates paid short, denials aging quietly past their appeal deadlines, and recovery work that never happens because nobody in the building has the hours to do it twice.

ClaimPilot is the audit he wanted standing behind every orthopedic book: an engine that checks each paid line against the contract, classifies every denial by reason and deadline, and puts a certified coder between the software and any finding a practice is asked to act on. Nothing is filed without approval — the same discipline of review before anything leaves the room.

Jacob Duncan, DO Board Certified Orthopedic Trauma Surgeon · Founder & CEO, ClaimPilot AI

For Billing Companies & RCM Firms

Offer a recovery audit under your brand. We run the engine underneath.

Our partner program lets billing companies offer the audit to their orthopedic clients under their own name. You own the client relationship, present the findings, and keep the credit — because it was your service that found the money. We stay invisible unless you want us in the room.

Start the same way your clients do: one free sample audit on one client's data, findings under your brand, no obligation. Partner terms are set out in a written term sheet, walked through together on a call — nothing improvised.

How the partner program works The free sample audit

Questions

Frequently asked questions

How do you handle HIPAA and our patients' data?

No data changes hands until a Business Associate Agreement (BAA) is signed — or the data is fully de-identified first. All work runs on HIPAA-eligible, BAA-covered infrastructure, encrypted in transit and at rest, with role-based access and audit logging. Your data is used only to perform your audit: never sold, never shared outside the engagement, never used to train models.

What data do you need, and in what format?

Exports you already have: 837 claim files and 835 remittance files, plus your payer contract rate schedules so paid amounts can be compared against what was actually contracted. No new software, no integration, no workflow change for your staff. If a contract schedule isn't available for a payer, the audit can still run against a Medicare baseline — those findings are labelled "benchmark variance," because without the contract we don't claim to know what was owed.

Who reviews the findings?

A certified coder reviews every finding before it is delivered. The engine proposes; a qualified human signs off. The same rule applies to appeals: every appeal is drafted for review, and nothing is submitted to a payer without the practice's approval.

How does pricing work?

The sample audit is free. After that, a 90-day pilot runs on contingency: 20% of verified recovered revenue, with a $750/month floor and a $10,000/month cap per practice. "Recovered" means paid by the payer and posted, verified on your own 835 remittance data, on a claim the audit flagged and worked, within a 180-day attribution window. If a payer recoups a payment, the corresponding fee is credited back. No recovery, no contingency fee.

Do you submit appeals to payers yourselves?

No. We deliver the recovery report and drafted appeals; you review and approve everything, and submissions go to payers under your control. Nothing leaves without approval.

What if the audit finds nothing?

Then you've gained a verified clean bill of health for that slice of your book — and if it was the sample audit, it cost you nothing. We hold ourselves to a bar of identifying at least 10× the fee in credible recoverable revenue; if the findings aren't there, the honest recommendation is not to continue.

Is this only for orthopedic practices?

Orthopedics is where the audit logic is deepest — global periods, modifiers, implant reimbursement — and it's our focus. The underlying mechanics (contract variance, denial classification, deadline tracking) apply to other procedure-heavy specialties; ask us if your specialty isn't ortho.

Contact

Start with the free sample audit

One practice, one month of remittances or one payer's problem lines, findings back within five business days of receiving complete data. Tell us whether you're a practice or a billing partner, and we'll walk you through the data handoff — BAA first, always.

Email us about a sample audit aspiringortho@gmail.com

Jacob Duncan, DO · Board Certified Orthopedic Trauma Surgeon · Founder & CEO, ClaimPilot AI · getclaimpilot.ai