REPORT 01 · DENIALS · ROOT CAUSE
Avoidable vs unavoidable denials
Two-thirds of FFS BH denials are preventable if you catch them upstream. CYBX classifies every denial by root cause and tells you where in the workflow to fix it.
Total denials
$487K
+12% vs prior 90d
Avoidable
$361K
74% of denials
Prevented this period
$94K
CYBX upstream catches
Unavoidable
$126K
payer + medical necessity
Denials by root cause
Avoidable bucket is fixable through process and AI. Unavoidable bucket feeds payer renegotiation.
AVOIDABLE 75%
UNAVOIDABLE 25%
Where to fix it
Each avoidable bucket maps to a specific workflow shift.
01
Eligibility / VOB error · 28%
Catch at intake. Real-time eligibility check before scheduling.
02
Missing or expired auth · 19%
Concurrent review countdown. Alerts 14 days before expiry.
03
Modifier or POS mismatch · 13%
AI flag on submission. Telehealth modifier audit (Report 03).
04
Untimely filing · 8%
Notes-not-locked aging triggers escalation to clinician.
05
Coding / documentation · 7%
Pattern detection on prior denials. Pre-submission flag.
Top denials by payer + root cause
Click any row to drill to claim-level detail. Action column drives the billing manager's worklist priority.
| Payer | Root cause | Bucket | Claims | Dollars | Recommended action |
|---|---|---|---|---|---|
| Aetna Commercial | Eligibility / VOB error | Avoidable | 87 | $54,210 | Intake VOB process review |
| BCBS PPO | Missing or expired auth | Avoidable | 62 | $41,880 | Auth tracker auto-alerts |
| UHC Optum BH | Modifier or POS mismatch | Avoidable | 119 | $37,605 | Telehealth audit (Report 03) |
| Cigna Behavioral | Medical necessity | Unavoidable | 28 | $22,440 | Appeal + parity evidence |
| Medicaid (state) | Untimely filing | Avoidable | 71 | $18,920 | Notes-not-locked escalation |
| Aetna Commercial | Retroactive eligibility term | Unavoidable | 15 | $11,250 | Patient outreach + write-off |
Key insight:
75 percent of denial dollars are sitting in the avoidable bucket. Fixing the top three root causes (eligibility, auth, modifiers) recovers an estimated $133K per quarter without touching the appeals queue.
Sample data shown for illustration. Benchmarks: AMA, PIMSY, BillingParadise, MGMA. CYBX classification model trained on practice-specific denial history plus published payer remit code patterns.
REPORT 02 · DENIALS · RECOVERY ECONOMICS
Cost-to-collect per denied dollar
When working a denial costs more than recovering it, the math says write off. CYBX makes the call explicit by claim, by payer, by dollar size.
Avg cost per recovered $
$0.37
$0.50 = write-off threshold
Denial recovery rate
62%
+8 pts vs baseline
Recovered this period
$215K
on $361K avoidable
Smart-write-off saved
$28K
staff time redirected
Claims by dollar size vs work effort
Above the dashed line, work the claim. Below, write off. Threshold tunable per payer.
This week's recommendation
Math-driven triage for the billing manager.
Work these claims
412 claims
$184,200 expected recovery at avg $0.31 cost-to-collect.
Write off
237 claims
$8,940 face value at avg $0.71 cost-to-collect.
Threshold by payer
| Payer | Threshold | Recovery rate |
|---|---|---|
| Aetna Commercial | $0.42 | 71% |
| BCBS PPO | $0.38 | 68% |
| UHC Optum BH | $0.51 | 54% |
| Cigna Behavioral | $0.45 | 61% |
| Medicaid (state) | $0.62 | 42% |
Key insight:
Smart triage redirects staff time from low-margin small claims to the high-yield avoidable bucket. Net effect: recovery rate climbs while total recovery cost falls.
Sample data shown for illustration. CYBX recommendation engine factors: avg appeal cycle time per payer, historical reversal rate by denial code, billing manager hourly fully-loaded cost. Calibration: MGMA "Beyond Days in A/R", HFMA cost-to-collect benchmarks.
REPORT 03 · PREVENTION · TELEHEALTH
Telehealth modifier and POS audit
Place of service 02 vs 10 swings $58 per visit. Modifier 95 vs 93 plus state parity rules drive 30 to 40 percent of telehealth claim failures. CYBX flags every mismatch before submission.
Mismatches detected
183
10% of telehealth volume
$ at risk
$10.6K
avg $58/visit on POS
Caught pre-submission
156
85% prevention rate
Recovered post-denial
$8.2K
26 claims, modifier appeal
Modifier compliance by payer
Heat map of compliance rate per payer per modifier rule. Red cells are payer-specific gotchas that CYBX flags pre-submission.
PAYER
POS 10 home
POS 02 elsewhere
Mod 95 A/V
Mod 93 audio
State parity
Aetna Commercial
98%
96%
99%
71%
94%
BCBS PPO
95%
68%
97%
89%
73%
UHC Optum BH
42%
61%
93%
38%
58%
Cigna Behavioral
91%
88%
94%
76%
90%
Medicaid (state)
74%
86%
95%
88%
44%
85% or above
50-84%
Below 50%
Open mismatches this week
Worklist for the billing manager. CYBX has staged the corrected submission for review.
| Date | Patient ID | Clinician | Payer | Detected issue | $ at risk | CYBX recommendation |
|---|---|---|---|---|---|---|
| Apr 28 | PT-4821 | Dr. Mehta | UHC Optum BH | POS 02 used, patient at home | $58 | Resubmit POS 10 |
| Apr 28 | PT-3047 | L. Park, LCSW | BCBS PPO | Mod 95 on audio-only session | $112 | Change to Mod 93, resubmit |
| Apr 27 | PT-5892 | Dr. Mehta | UHC Optum BH | Audio-only without Mod 93 | $112 | Add Mod 93, resubmit |
| Apr 26 | PT-2113 | R. Daniels, LMFT | Medicaid (NY) | State parity rule: in-state requirement | $84 | Verify provider state license |
| Apr 25 | PT-4109 | L. Park, LCSW | Aetna Commercial | Mod 93 on synchronous session | $96 | Change to Mod 95, resubmit |
Key insight:
UHC Optum BH compliance is the largest exposure: POS 10 at 42% and Mod 93 at 38%. Targeted training plus pre-submission rule overlay closes the gap before submission.
Sample data shown for illustration. Sources: CMS Telehealth FAQ Feb 2026, CY2026 PFS final rule. State parity rules tracked across all 50 states with payer-specific overlays. CYBX rule library updates monthly.
REPORT 04 · ENGAGEMENT
Intake-to-engagement funnel
Most BH dashboards stop at no-show rate and miss the funnel above and below it. Of 100 inquiries, only 20 stay active at 90 days. Marketing spend and capacity decisions ride on this view.
Inquiries
342
+18% vs prior 90d
Intake completed
178
52% conversion
First treatment session
119
35% of inquiries
Active at 90 days
71
21% (vs 20% benchmark)
Funnel
Industry benchmark: 100 / 50 / 33 / 20. Lakeside is performing slightly above benchmark on intake conversion, slightly below on first-session conversion.
342
52% intake conversion (benchmark 50%)
178
67% to first session (benchmark 66%)
119
60% retention to 90 days (benchmark 60%)
71
Where dropoff is happening
Days from inquiry to next stage. Long waits drive dropoff.
Conversion by referral source
Drives marketing spend allocation. CYBX attributes inquiries through admission and computes cost-per-active-patient by channel.
| Referral source | Inquiries | Intake | First session | Active 90d | End-to-end conv. | Status |
|---|---|---|---|---|---|---|
| Direct PCP referral | 94 | 61 | 48 | 31 | 33% | Strong |
| EAP partner (Lyra) | 71 | 52 | 39 | 18 | 25% | On-benchmark |
| Self-referral / web | 88 | 31 | 15 | 9 | 10% | Investigate |
| Payer directory | 43 | 19 | 11 | 7 | 16% | Below avg |
| Existing patient referral | 31 | 11 | 5 | 5 | 16% | Small sample |
| Court / court-ordered | 15 | 4 | 1 | 1 | 7% | Reassess |
Key insight:
Self-referral / web is the largest inquiry source but the weakest converter. Speed-to-lead automation closes the gap; expect a 2x improvement on intake conversion within 30 days of activation.
Sample data shown for illustration. Benchmarks: Hamm Clinic Attrition in Psychotherapy survival analysis, APA dropout meta-analysis, Mend BH no-show research.