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--- guides:sharpinsight [2026/07/24 19:48] – Add Worked & Resubmitted, Diagnosis Ordering Impact, and AI Rule Suggestions reports brad.sharp
+++ guides:sharpinsight [2026/09/17 14:41] (current) – Add Preventable Revenue Loss report (Coding & Compliance) and the Patient Responsibility Codes setting brad.sharp
@@ Line 302: / Line 302: @@
 ===== Coding & Compliance =====
-Reports for tracking procedure code changes, CARC trends, profitability, and contracted rates.
+Reports for tracking procedure code changes, CARC trends, preventable patient balances, profitability, and contracted rates.
 ==== Procedure Code Changes ====
@@ Line 331: / Line 331: @@
   * Watch for CARC codes that are trending upward month-over-month — they may indicate new payer rules or process breakdowns.
   * Cross-reference with the **Denial Root Cause** report for a complete picture of adjustment impacts.
+==== Preventable Revenue Loss ====
+//New in September 2026.//
+Finds patient balances that are worth a second look before anyone collects them, groups them by the **process failure that produced them**, and shows whether each of those processes is getting better or worse month over month.
+Some of what it finds is still recoverable from the payer. The rest is money to stop losing next month. That is the point of the report: a single total is an invoice, but a category trending the wrong way is a reason to change something.
+<WRAP center round info 90%>
+**Legitimate cost sharing is never flagged.** Deductible (PR-1), coinsurance (PR-2) and copay (PR-3) are shown alongside the findings for scale only. None of it is a problem.
+</WRAP>
+=== Running the report ===
+Choose a **Start Date** and **End Date**, optionally enter a **Payer Number**, and click **Search**. When a payer filter is applied a banner appears at the top reminding you that every figure below is for that payer alone, with a **Show all payers** button to clear it.
+=== The headline numbers ===
+^ Metric ^ Description ^
+| **Preventable** | The slice your own process could have stopped: missed authorizations, late filing, claim data errors, duplicates, unverified eligibility. This is the number to manage against. |
+| **Still Recoverable** | Balances that can still be appealed or corrected and resubmitted, before the window closes. |
+| **Already Paid** | The payer settled this on an earlier remittance. Not a loss. Only shown when there is some. |
+| **Payer Caused** | Not your process. Escalate these with the payer. Only shown when there is some. |
+| **Total Flagged** | Everything the report flagged, and the number of claims behind it. Includes amounts that are not losses, so this is the widest number, not the actionable one. |
+| **Legitimate Cost Sharing** | Deductible, coinsurance and copay for the same period. Context, not a finding. |
+=== "What was checked" ===
+Directly under the headline numbers is a card showing how many ERAs were scanned, how many carried patient responsibility, and which reason codes were applied.
+**Read this before concluding you have no problem.** An empty report has three very different causes, and this card tells you which one you are looking at:
+  * No ERAs were received in the date range, so there was nothing to check
+  * No codes are configured for your account, so nothing could be flagged
+  * There genuinely were no findings
+The card also lists anything that could **not** be evaluated, so you know what is missing from the totals, and warns you if the detail list at the bottom was shortened (the totals always cover everything).
+=== What to fix, and whether it is improving ===
+Each finding is assigned a **prevention category**: the process that failed. Every category comes with the change that stops the next one, plus a month-by-month bar strip so you can see the direction of travel.
+^ Category ^ What to change ^
+| Authorization not obtained | Verify and record authorization before the service is rendered. |
+| Filed too late | Shorten the gap between service and submission, and watch the oldest unbilled claims. |
+| Claim data errors | Tighten claim scrubbing at entry so these are caught before submission. |
+| Coding | Review coding and documentation for these services with the coding team. |
+| Duplicate submission | Check submission controls. These claims went out more than once. |
+| Eligibility not verified | Run eligibility before billing so protected patients are flagged up front. |
+| Payer error (not yours) | Not a process failure on your side. Escalate these with the payer. |
+| Already paid (not a loss) | Confirm the earlier payment posted before deciding how to handle the balance. |
+=== Actions ===
+Every flagged balance carries an **Action** badge telling the biller what to look at next.
+^ Action ^ Meaning ^
+| **Appeal** | Worth appealing to the payer. |
+| **Correct & resubmit** | Fix the claim and send it again. |
+| **Write off** | Not collectable and not recoverable. |
+| **Review** | Needs a human look before it is categorised. |
+| **Verify** | Stop and confirm the situation before deciding how to handle the balance. |
+A smaller note beside the action says **why** the row was flagged: //Not patient liability//, //Medicaid cost share//, or //QMB protected patient//.
+=== QMB patients needing review ===
+Where eligibility reports a patient as a Qualified Medicare Beneficiary but the check could not be confirmed for the service dates, those patients are **listed individually** in their own section with the member ID, payer, reported coverage status, why it needs review, when the check ran, and the coverage period.
+These rows are **excluded from every total above**. Confirm coverage before deciding how to handle them.
+<WRAP center round important 90%>
+QMB findings only appear for accounts that run eligibility through Sharp Revenue. If the "What was checked" card says QMB was not evaluated, that is the reason. See the [[guides:patient-coverage-on-claims|Patient Coverage on Claims]] guide.
+</WRAP>
+=== The tables ===
+  * **By Reason Code** — each code with its meaning, claim and adjustment counts, action, prevention category, and total
+  * **By Payer** — grouped by the payer number on the remittance, with recoverable and total amounts, and a **Filter** button to drill the whole report into one payer. A payer that sends more than one payer number appears on more than one row.
+  * **Affected Claims** — the individual balances: patient account number, patient, payer, code, action, amount, and ERA received date. Sortable and paged.
+**Tips:**
+  * **Watch the trend per category, not the single total.** A category going the wrong way is the signal worth acting on.
+  * **Start with Preventable, not Total Flagged.** Total Flagged deliberately includes amounts that are not losses.
+  * **Configure your codes.** The code list and the action assigned to each one are per account, under **Analytics Settings**. Adjust them if a contract genuinely permits patient responsibility where the standard discourages it.
+  * **Totals will not tie out against CARC Trends.** That report reads service-line adjustments only, while this one reads both claim-level and line-level amounts.
 ==== Procedure Profitability ====
@@ Line 545: / Line 632: @@
   * **Similarity settings** — Set the minimum similarity score and maximum results for the Claim Similarity report
   * **CARC exclusions** — Exclude specific CARC codes from trending and analysis
+  * **Patient responsibility codes & actions** — The reason codes that the **Preventable Revenue Loss** report flags, and the action assigned to each one. Legitimate cost sharing (PR-1 deductible, PR-2 coinsurance, PR-3 copay) is never flagged. Use **Restore Defaults** to load the standard set, then add, remove, or re-assign actions to match your contracts. With no codes configured, the report flags nothing.
   * **Denial settings** — Configure write-off threshold days and appeal detection behavior
@@ Line 550: / Line 638: @@
 //Need help? Contact ClaimRev support at [[mailto:help@claimrev.com|help&#64;claimrev.com]] or call 918-842-9564.//