Revenue cycle services — NAKIRA Solutions

The organizing idea

We work the back end to fix the front end.

Reworking a denied claim runs upward of $25 in administrative time, and considerably more once it goes to appeal. Meanwhile 41% of surveyed billing and finance leaders now report denial rates of 10% or higher, up from 30% in 2022. Rework is the most expensive way to get paid, and it doesn't stop the next one.

The evidence for why a denial happened lives at the back of the cycle, in the remittance. The fix almost always belongs at the front — in how the patient was registered, whether coverage was verified, whether the authorization was on file, whether the provider was enrolled, whether the note supported the code. So that's how we work: mine the back end for the cause, then close the gap at intake.

Rework cost: industry benchmarking compiled from MGMA, HFMA, CMS, PNC Financial Services, and The Advisory Board Company. Denial rates: Experian Health, State of Claims 2025 — a survey of 250 healthcare professionals responsible for financial, billing, or claims management decisions, fielded June–July 2025.

Front end

Stop the denial before there's a claim.

The cheapest denial is the one that never becomes a claim. Everything here happens before or at the visit.

Eligibility & benefits verification. We confirm coverage, plan, copay, deductible, coinsurance, and visit caps ahead of the visit — then return it as a pre-visit action plan rather than a benefits dump. Not "here's the coverage response," but bill this payer first, obtain this authorization, collect this amount at check-in. The action-plan engine is built and demonstrated on sample responses; real-time eligibility goes live with your BAA and payer enrollment, and until then we verify by portal or payer call and load the result.
Coordination of benefits. Establish the correct payer order before you bill, so the claim isn't denied for a reason no amount of clean coding can fix.
Prior-authorization management. Requirements flagged before submission, plus an authorization register tracking what's on file, units remaining, and expiry — so a valid authorization is matched to the claim and an exhausted one raises a warning instead of a denial. When a service needs authorization we assemble the request from the known administrative facts and a person completes the clinical justification from the record. We never assert medical necessity the documentation doesn't support.
A flag is a prompt, not a verdict. We tell you what we think and why, and where it needs confirming with the member’s plan we say so rather than guessing on your behalf.
Patient estimates. No Surprises Act Good Faith Estimates — itemized for self-pay or as an advanced-EOB patient share — built from your fee schedule and the verified eligibility, for your team to review and issue.

Mid cycle

Send it clean the first time.

This is where most vendors start and stop. For us it's the middle of a longer loop.

Medical billing & coding. Charge capture through payment, with coding accuracy checked against the national CMS rulebook before anything goes out — NCCI bundling with the modifier indicator, MUE unit caps, MPFS pricing and globals.
Claim integrity review. Covered-diagnosis and LCD checks per procedure, modifier policy, and prior-auth-required flags — so the claim leaves with the support it needs, not just a valid code.
Documentation review. The note read against the procedure billed: procedure support, laterality against the modifier, imaging guidance, and the documentation cues that specialty's notes should contain.
Submission. We get claims out the door and remittances back, reconciled — submitted through your existing clearinghouse and PM system, with Provira scrubbing before they go and matching the remits when they return. (Provira submitting on your behalf is on the roadmap for the Complete tier; today the claim leaves through your pipe.)

Back end

Recover what you're owed, and stop losing it twice.

And extract the lesson, so the same money doesn't get stuck twice.

Denial management. Every denied line becomes a work item carrying the payer, the reason code, the dollars at risk, and — for most denials, because it's the same rule that would have caught it — the root cause and the corrected coding. The queue triages by recoverable dollars, deadline urgency, payer, and reason, and we track the filing and appeal deadline on every item, so a deadline is somebody's job instead of nobody's. Work is claimed and locked to one person, so two people never work the same denial.
Appeals. A managed queue rather than a letter generator. Every appealable denial ranked by deadline and by overturn odds — strong, even, or long shot — with the argument that has historically worked for that payer and reason, and the payer's appeal requirements pulled together for you, each shown with its source and flagged to verify with the payer. Every appeal is reviewed by a person before it goes anywhere.
A/R follow-up. Aging worked by dollars and age rather than alphabetically, with no-response detection on stalled claims. We draft the status inquiry, work the portal or the phone, and record what the payer said next to each claim's age. (Automated 276/277 status arrives with clearinghouse connectivity.)
Underpayment recovery. Every paid line compared against the expected allowed amount — your contracted rate where you've given us the fee schedule, a Medicare benchmark where you haven't. Paid-but-short claims surface with the shortfall and a reprocessing request drafted — money most practices never chase because they never see it.
Credentialing & enrollment. The provider-identifier denials that quietly reject every claim for one provider, rolled into cases by provider and payer with dollars held and days open — plus a roster that flags a new claim for a provider who isn't enrolled yet, before it goes out, so it's held rather than denied.

What you see

You get the reporting, not just the result.

You see the same reporting we work from: what's denying, by payer, and whether it's covered, still being learned, or a gap. Rates trended over time — and, as the network grows, your numbers against the de-identified specialty median.

Money we recovered and money we prevented are reported as two separate numbers, never blended into one flattering total. See the reporting in detail.

How we work with you

Your team keeps the access it should have.

We don't take your practice management system away from your staff. Your team keeps working in the tools they already use, with their own logins and their own access, and we work the queues alongside them — however much of the cycle you've handed us.

Who can see and do what is set by an administrator at your practice, never chosen by the user, and every status change, rule promotion, and appeal is written to an audit trail. How access works, role by role.

Full authentication-backed access control and database-level audit logging are part of our production hardening — we'd rather walk your security reviewer through the current state than assert it here.