Observed Finding
The Analysis Found a $251,000 Opportunity. Now Inspect the Evidence.
This is an Observed Finding from Harbor Ridge Scenario 1's frozen blind-test output — not a Benchmark Result.
How this Number is Derived
In-network (INN) claims
Billed$1,216,954.73
Collected$812,530.95
Realization rate66.77%
Out-of-network (OON) claims
Billed$688,137.27
Collected$209,054.85
Realization rate30.38%
The counterfactual
If OON claims had collected at the INN realization rate instead of their own:
OON billed$688,137.27
INN rate66.77%
Expected OON collections$459,452.45
Minus what OON claims actually collected:
Expected OON collections$459,452.45
Actual OON collected$209,054.85
Estimated gap$250,397.60
Inspect the Underlying Claim-Level Records (160 claims)
| Opportunity | Payer | Episode | Claim | Billed | Allowed | Collected | Status |
|---|---|---|---|---|---|---|---|
| HRO-000002 | INN | KIPU-000001 | CLM-000001 | $9,148.49 | $6,777.89 | $7,188.97 | Closed |
| HRO-000002 | INN | KIPU-000001 | CLM-000002 | $8,700.16 | $6,999.61 | $6,926.85 | Closed |
| HRO-000004 | INN | KIPU-000002 | CLM-000003 | $14,474.24 | $11,019.19 | $11,671.40 | Closed |
| HRO-000009 | INN | KIPU-000004 | CLM-000005 | $12,713.28 | $10,702.42 | $11,544.90 | Closed |
| HRO-000026 | INN | KIPU-000006 | CLM-000007 | $24,414.73 | $20,214.76 | $18,653.20 | Paid |
| HRO-000028 | INN | KIPU-000007 | CLM-000008 | $9,880.02 | $7,724.83 | $8,041.80 | Closed |
| HRO-000044 | INN | KIPU-000009 | CLM-000010 | $14,109.15 | $10,947.46 | $11,475.74 | Closed |
| HRO-000046 | INN | KIPU-000010 | CLM-000011 | $7,425.08 | $5,677.06 | $5,441.48 | Paid |
| HRO-000046 | INN | KIPU-000011 | CLM-000012 | $21,388.50 | $15,611.40 | $15,809.60 | Closed |
| HRO-000059 | INN | KIPU-000014 | CLM-000016 | $9,824.17 | $8,138.48 | $7,948.86 | Closed |
| HRO-000059 | INN | KIPU-000015 | CLM-000017 | $10,090.10 | $8,567.38 | $0.00 | Appealed |
| HRO-000073 | INN | KIPU-000019 | CLM-000021 | $8,537.71 | $6,223.75 | $5,632.02 | Paid |
| HRO-000073 | INN | KIPU-000020 | CLM-000022 | $15,511.73 | $12,582.22 | $12,644.03 | Closed |
| HRO-000095 | INN | KIPU-000021 | CLM-000023 | $23,341.63 | $18,066.90 | $16,709.67 | Paid |
| HRO-000098 | INN | KIPU-000022 | CLM-000024 | $7,649.50 | $5,543.81 | $5,967.60 | Closed |
| HRO-000104 | INN | KIPU-000023 | CLM-000025 | $9,386.11 | $6,842.59 | $6,840.93 | Closed |
| HRO-000105 | INN | KIPU-000024 | CLM-000026 | $14,301.55 | $12,028.99 | $12,474.61 | Closed |
| HRO-000106 | INN | KIPU-000025 | CLM-000027 | $4,611.69 | $3,694.96 | $3,748.08 | Closed |
| HRO-000106 | INN | KIPU-000026 | CLM-000028 | $9,672.18 | $7,877.61 | $8,213.18 | Closed |
| HRO-000129 | INN | KIPU-000028 | CLM-000030 | $11,756.26 | $9,204.84 | $8,834.91 | Paid |
| HRO-000140 | INN | KIPU-000031 | CLM-000033 | $5,727.27 | $4,772.04 | $4,877.75 | Closed |
| HRO-000152 | INN | KIPU-000033 | CLM-000035 | $9,357.77 | $7,190.32 | $7,070.02 | Paid |
| HRO-000152 | INN | KIPU-000034 | CLM-000036 | $15,146.86 | $11,069.15 | $11,268.68 | Closed |
| HRO-000159 | INN | KIPU-000035 | CLM-000037 | $17,344.91 | $14,428.91 | $13,820.08 | Paid |
| HRO-000166 | INN | KIPU-000037 | CLM-000040 | $6,407.32 | $5,260.99 | $0.00 | Appealed |
| HRO-000166 | INN | KIPU-000038 | CLM-000041 | $21,138.73 | $16,714.49 | $18,217.52 | Closed |
| HRO-000167 | INN | KIPU-000039 | CLM-000042 | $7,894.94 | $6,536.53 | $6,526.32 | Paid |
| HRO-000167 | INN | KIPU-000040 | CLM-000043 | $8,200.29 | $5,999.06 | $5,844.08 | Paid |
| HRO-000167 | INN | KIPU-000040 | CLM-000044 | $9,291.65 | $7,683.53 | $8,050.57 | Closed |
| HRO-000168 | INN | KIPU-000041 | CLM-000045 | $10,820.96 | $8,358.51 | $8,709.27 | Closed |
| HRO-000168 | INN | KIPU-000041 | CLM-000046 | $10,429.44 | $8,493.91 | $8,301.00 | Closed |
| HRO-000178 | INN | KIPU-000045 | CLM-000052 | $8,181.54 | $6,562.70 | $6,655.17 | Closed |
| HRO-000187 | INN | KIPU-000046 | CLM-000053 | $13,865.67 | $10,774.38 | $10,579.46 | Paid |
| HRO-000200 | INN | KIPU-000048 | CLM-000056 | $13,906.34 | $10,070.80 | $9,497.06 | Paid |
| HRO-000203 | INN | KIPU-000050 | CLM-000058 | $9,701.22 | $8,062.23 | $8,203.99 | Closed |
| HRO-000203 | INN | KIPU-000051 | CLM-000059 | $17,948.48 | $14,243.88 | $13,256.63 | Paid |
| HRO-000204 | INN | KIPU-000052 | CLM-000060 | $10,386.12 | $8,047.04 | $8,252.57 | Closed |
| HRO-000204 | INN | KIPU-000052 | CLM-000061 | $10,382.62 | $8,723.58 | $9,100.27 | Closed |
| HRO-000206 | INN | KIPU-000053 | CLM-000062 | $12,576.24 | $10,230.53 | $10,383.17 | Closed |
| HRO-000221 | INN | KIPU-000055 | CLM-000064 | $6,193.12 | $5,216.64 | $4,969.52 | Paid |
| HRO-000221 | INN | KIPU-000056 | CLM-000065 | $20,246.28 | $15,674.45 | $14,647.02 | Paid |
| HRO-000226 | INN | KIPU-000058 | CLM-000068 | $10,696.58 | $8,888.56 | $8,805.01 | Paid |
| HRO-000248 | INN | KIPU-000062 | CLM-000072 | $13,547.49 | $10,231.53 | $9,745.33 | Paid |
| HRO-000249 | INN | KIPU-000063 | CLM-000073 | $4,454.09 | $3,355.34 | $3,413.44 | Closed |
| HRO-000264 | INN | KIPU-000066 | CLM-000076 | $4,671.63 | $3,859.71 | $4,031.64 | Closed |
| HRO-000264 | INN | KIPU-000066 | CLM-000077 | $4,160.93 | $3,214.95 | $3,161.38 | Closed |
| HRO-000267 | INN | KIPU-000068 | CLM-000079 | $14,583.84 | $10,754.32 | $10,493.50 | Paid |
| HRO-000270 | INN | KIPU-000069 | CLM-000080 | $7,932.08 | $6,370.79 | $6,406.72 | Closed |
| HRO-000270 | INN | KIPU-000070 | CLM-000081 | $22,278.05 | $16,173.80 | $16,166.62 | Paid |
| HRO-000283 | INN | KIPU-000074 | CLM-000086 | $18,049.72 | $13,232.48 | $12,810.44 | Paid |
| HRO-000296 | INN | KIPU-000076 | CLM-000088 | $5,351.19 | $4,429.57 | $4,411.20 | Closed |
| HRO-000296 | INN | KIPU-000077 | CLM-000089 | $24,939.20 | $20,071.13 | $19,996.19 | Paid |
| HRO-000301 | INN | KIPU-000078 | CLM-000090 | $3,629.45 | $2,886.47 | $3,177.18 | Closed |
| HRO-000302 | INN | KIPU-000079 | CLM-000091 | $3,757.75 | $3,144.76 | $3,161.47 | Closed |
| HRO-000302 | INN | KIPU-000079 | CLM-000092 | $4,615.48 | $3,570.53 | $3,608.54 | Closed |
| HRO-000302 | INN | KIPU-000080 | CLM-000093 | $22,458.71 | $19,011.73 | $17,915.06 | Paid |
| HRO-000303 | INN | KIPU-000081 | CLM-000094 | $8,805.61 | $6,832.47 | $7,287.68 | Closed |
| HRO-000303 | INN | KIPU-000082 | CLM-000095 | $14,500.37 | $11,563.36 | $11,831.55 | Closed |
| HRO-000307 | INN | KIPU-000083 | CLM-000096 | $7,664.66 | $5,807.38 | $6,249.45 | Closed |
| HRO-000314 | INN | KIPU-000086 | CLM-000099 | $5,182.34 | $4,041.57 | $4,082.79 | Closed |
| HRO-000315 | INN | KIPU-000087 | CLM-000100 | $26,505.70 | $20,908.33 | $20,715.28 | Paid |
| HRO-000317 | INN | KIPU-000089 | CLM-000103 | $4,288.29 | $3,481.92 | $3,514.60 | Closed |
| HRO-000317 | INN | KIPU-000090 | CLM-000104 | $19,789.91 | $16,647.89 | $16,639.97 | Paid |
| HRO-000324 | INN | KIPU-000092 | CLM-000106 | $6,037.31 | $4,417.84 | $4,272.94 | Closed |
| HRO-000324 | INN | KIPU-000093 | CLM-000107 | $16,582.36 | $12,539.10 | $12,181.22 | Paid |
| HRO-000326 | INN | KIPU-000094 | CLM-000108 | $21,179.50 | $17,094.10 | $16,556.78 | Paid |
| HRO-000331 | INN | KIPU-000095 | CLM-000109 | $21,579.41 | $17,438.93 | $17,030.31 | Closed |
| HRO-000337 | INN | KIPU-000099 | CLM-000113 | $19,204.94 | $15,309.56 | $15,861.42 | Closed |
| HRO-000338 | INN | KIPU-000100 | CLM-000114 | $6,524.01 | $4,993.05 | $4,888.87 | Closed |
| HRO-000338 | INN | KIPU-000101 | CLM-000115 | $25,120.17 | $19,049.08 | $19,900.63 | Closed |
| HRO-000345 | INN | KIPU-000105 | CLM-000119 | $6,406.32 | $5,068.42 | $5,100.29 | Closed |
| HRO-000345 | INN | KIPU-000106 | CLM-000120 | $14,953.65 | $11,338.02 | $10,520.78 | Paid |
| HRO-000356 | INN | KIPU-000109 | CLM-000124 | $17,351.98 | $13,623.18 | $13,661.71 | Closed |
| HRO-000364 | INN | KIPU-000110 | CLM-000125 | $20,652.50 | $15,924.95 | $0.00 | Denied |
| HRO-000377 | INN | KIPU-000113 | CLM-000128 | $21,257.39 | $17,874.32 | $0.00 | Denied |
| HRO-000389 | INN | KIPU-000115 | CLM-000130 | $3,735.41 | $3,169.92 | $2,930.77 | Paid |
| HRO-000389 | INN | KIPU-000116 | CLM-000131 | $15,018.67 | $12,671.53 | $0.00 | Pending |
| HRO-000397 | INN | KIPU-000118 | CLM-000133 | $24,214.61 | $17,552.51 | $0.00 | Pending |
| HRO-000407 | INN | KIPU-000121 | CLM-000137 | $5,220.83 | $4,289.81 | $4,014.05 | Paid |
| HRO-000407 | INN | KIPU-000122 | CLM-000138 | $12,528.52 | $9,868.08 | $0.00 | Pending |
| HRO-000413 | INN | KIPU-000125 | CLM-000141 | $4,140.01 | $3,088.71 | $2,903.95 | Paid |
| HRO-000413 | INN | KIPU-000125 | CLM-000142 | $3,580.78 | $2,600.92 | $2,471.66 | Paid |
| HRO-000413 | INN | KIPU-000126 | CLM-000143 | $16,757.99 | $12,707.13 | $12,109.00 | Paid |
| HRO-000418 | INN | KIPU-000127 | CLM-000144 | $9,622.03 | $7,401.27 | $7,043.79 | Paid |
| HRO-000418 | INN | KIPU-000128 | CLM-000145 | $10,210.22 | $8,225.64 | $7,615.92 | Paid |
| HRO-000426 | INN | KIPU-000129 | CLM-000146 | $9,758.92 | $7,170.46 | $6,934.43 | Paid |
| HRO-000429 | INN | KIPU-000130 | CLM-000147 | $16,928.49 | $13,425.69 | $12,953.70 | Paid |
| HRO-000430 | INN | KIPU-000131 | CLM-000148 | $5,230.72 | $4,339.49 | $4,416.50 | Closed |
| HRO-000437 | INN | KIPU-000133 | CLM-000150 | $6,190.78 | $4,756.97 | $0.00 | Appealed |
| HRO-000447 | INN | KIPU-000134 | CLM-000151 | $16,049.14 | $13,056.85 | $12,438.17 | Paid |
| HRO-000455 | INN | KIPU-000137 | CLM-000154 | $4,569.26 | $3,788.58 | $3,851.22 | Closed |
| HRO-000460 | INN | KIPU-000138 | CLM-000155 | $7,089.93 | $5,957.91 | $6,330.16 | Closed |
| HRO-000460 | INN | KIPU-000138 | CLM-000156 | $6,709.42 | $5,343.95 | $5,765.12 | Closed |
| HRO-000486 | INN | KIPU-000143 | CLM-000162 | $6,791.80 | $5,377.94 | $5,277.90 | Paid |
| HRO-000486 | INN | KIPU-000143 | CLM-000163 | $7,151.79 | $5,271.97 | $5,525.14 | Closed |
| HRO-000498 | INN | KIPU-000144 | CLM-000164 | $15,895.03 | $12,499.90 | $0.00 | Pending |
| HRO-000508 | INN | KIPU-000145 | CLM-000165 | $7,432.41 | $5,870.58 | $5,570.95 | Paid |
| HRO-000508 | INN | KIPU-000146 | CLM-000166 | $26,640.17 | $21,441.98 | $0.00 | Submitted |
| HRO-000517 | INN | KIPU-000150 | CLM-000171 | $8,201.38 | $6,430.27 | $6,283.38 | Paid |
| HRO-000517 | INN | KIPU-000151 | CLM-000172 | $18,880.11 | $15,106.48 | $0.00 | Submitted |
| HRO-000520 | INN | KIPU-000152 | CLM-000173 | $7,609.65 | $6,405.25 | $6,497.17 | Closed |
| HRO-000008 | OON | KIPU-000003 | CLM-000004 | $7,695.29 | $3,654.22 | $4,531.10 | Closed |
| HRO-000017 | OON | KIPU-000005 | CLM-000006 | $23,827.05 | $9,926.41 | $9,590.22 | Paid |
| HRO-000034 | OON | KIPU-000008 | CLM-000009 | $29,074.28 | $14,605.49 | $16,529.17 | Closed |
| HRO-000048 | OON | KIPU-000012 | CLM-000013 | $2,852.73 | $1,271.32 | $1,524.67 | Closed |
| HRO-000048 | OON | KIPU-000012 | CLM-000014 | $2,854.85 | $1,488.02 | $1,341.14 | Paid |
| HRO-000048 | OON | KIPU-000013 | CLM-000015 | $21,571.38 | $10,452.31 | $12,642.27 | Closed |
| HRO-000062 | OON | KIPU-000016 | CLM-000018 | $14,915.23 | $7,850.46 | $0.00 | Appealed |
| HRO-000067 | OON | KIPU-000017 | CLM-000019 | $7,804.98 | $4,721.59 | $5,869.23 | Closed |
| HRO-000069 | OON | KIPU-000018 | CLM-000020 | $23,818.23 | $13,467.09 | $15,532.83 | Closed |
| HRO-000118 | OON | KIPU-000027 | CLM-000029 | $18,947.65 | $10,831.01 | $13,240.55 | Closed |
| HRO-000137 | OON | KIPU-000029 | CLM-000031 | $20,066.19 | $10,998.06 | $13,519.94 | Closed |
| HRO-000139 | OON | KIPU-000030 | CLM-000032 | $10,511.66 | $4,904.20 | $4,748.94 | Paid |
| HRO-000147 | OON | KIPU-000032 | CLM-000034 | $3,613.14 | $2,109.26 | $2,073.12 | Paid |
| HRO-000170 | OON | KIPU-000042 | CLM-000047 | $2,672.88 | $1,191.96 | $1,111.81 | Paid |
| HRO-000170 | OON | KIPU-000042 | CLM-000048 | $2,488.40 | $1,108.50 | $1,029.07 | Paid |
| HRO-000170 | OON | KIPU-000043 | CLM-000049 | $14,340.02 | $6,183.29 | $0.00 | Appealed |
| HRO-000175 | OON | KIPU-000044 | CLM-000050 | $8,887.94 | $5,480.26 | $0.00 | Appealed |
| HRO-000175 | OON | KIPU-000044 | CLM-000051 | $8,540.10 | $4,851.31 | $0.00 | Appealed |
| HRO-000198 | OON | KIPU-000047 | CLM-000054 | $11,556.58 | $4,954.91 | $4,651.45 | Paid |
| HRO-000198 | OON | KIPU-000047 | CLM-000055 | $12,373.98 | $5,876.01 | $7,271.08 | Closed |
| HRO-000202 | OON | KIPU-000049 | CLM-000057 | $9,425.76 | $4,418.65 | $4,363.85 | Paid |
| HRO-000207 | OON | KIPU-000054 | CLM-000063 | $21,824.60 | $13,230.42 | $13,051.81 | Paid |
| HRO-000229 | OON | KIPU-000059 | CLM-000069 | $11,907.97 | $5,563.94 | $5,207.29 | Paid |
| HRO-000229 | OON | KIPU-000060 | CLM-000070 | $17,705.72 | $7,316.23 | $7,307.88 | Paid |
| HRO-000234 | OON | KIPU-000061 | CLM-000071 | $15,136.82 | $7,584.89 | $0.00 | Appealed |
| HRO-000255 | OON | KIPU-000064 | CLM-000074 | $9,753.18 | $5,454.45 | $6,124.64 | Closed |
| HRO-000255 | OON | KIPU-000065 | CLM-000075 | $15,815.94 | $7,566.43 | $0.00 | Pending |
| HRO-000275 | OON | KIPU-000072 | CLM-000083 | $5,548.98 | $2,990.13 | $3,284.48 | Closed |
| HRO-000275 | OON | KIPU-000073 | CLM-000084 | $10,682.37 | $5,228.34 | $0.00 | Appealed |
| HRO-000275 | OON | KIPU-000073 | CLM-000085 | $10,227.73 | $6,244.35 | $0.00 | Denied |
| HRO-000309 | OON | KIPU-000084 | CLM-000097 | $7,323.22 | $3,460.42 | $3,352.12 | Paid |
| HRO-000309 | OON | KIPU-000085 | CLM-000098 | $12,981.91 | $5,950.10 | $5,493.31 | Paid |
| HRO-000316 | OON | KIPU-000088 | CLM-000101 | $9,419.86 | $4,991.88 | $4,737.94 | Paid |
| HRO-000316 | OON | KIPU-000088 | CLM-000102 | $9,351.27 | $5,184.96 | $0.00 | Appealed |
| HRO-000318 | OON | KIPU-000091 | CLM-000105 | $4,321.23 | $2,145.74 | $0.00 | Appealed |
| HRO-000334 | OON | KIPU-000096 | CLM-000110 | $8,556.11 | $4,476.17 | $4,292.81 | Paid |
| HRO-000334 | OON | KIPU-000097 | CLM-000111 | $19,262.60 | $12,080.31 | $0.00 | Denied |
| HRO-000336 | OON | KIPU-000098 | CLM-000112 | $11,841.42 | $6,315.13 | $7,012.15 | Closed |
| HRO-000343 | OON | KIPU-000103 | CLM-000117 | $22,431.35 | $10,810.47 | $0.00 | Denied |
| HRO-000344 | OON | KIPU-000104 | CLM-000118 | $11,524.82 | $5,257.86 | $4,930.48 | Paid |
| HRO-000353 | OON | KIPU-000107 | CLM-000121 | $3,102.80 | $1,553.67 | $1,512.81 | Paid |
| HRO-000353 | OON | KIPU-000107 | CLM-000122 | $5,044.43 | $2,637.59 | $2,574.09 | Paid |
| HRO-000353 | OON | KIPU-000108 | CLM-000123 | $23,675.72 | $13,322.93 | $0.00 | Pending |
| HRO-000374 | OON | KIPU-000111 | CLM-000126 | $4,891.16 | $2,446.78 | $2,896.17 | Closed |
| HRO-000374 | OON | KIPU-000112 | CLM-000127 | $26,416.02 | $12,767.58 | $0.00 | Pending |
| HRO-000378 | OON | KIPU-000114 | CLM-000129 | $5,753.48 | $2,608.95 | $0.00 | Pending |
| HRO-000393 | OON | KIPU-000117 | CLM-000132 | $8,847.53 | $3,999.92 | $0.00 | Pending |
| HRO-000408 | OON | KIPU-000123 | CLM-000139 | $6,659.12 | $4,306.23 | $4,802.46 | Closed |
| HRO-000408 | OON | KIPU-000124 | CLM-000140 | $17,695.25 | $7,370.45 | $0.00 | Pending |
| HRO-000436 | OON | KIPU-000132 | CLM-000149 | $8,059.44 | $4,363.44 | $0.00 | Pending |
| HRO-000450 | OON | KIPU-000135 | CLM-000152 | $6,545.01 | $3,497.47 | $0.00 | Denied |
| HRO-000450 | OON | KIPU-000136 | CLM-000153 | $17,494.31 | $7,133.93 | $0.00 | Pending |
| HRO-000463 | OON | KIPU-000139 | CLM-000157 | $14,029.62 | $8,201.41 | $0.00 | Pending |
| HRO-000470 | OON | KIPU-000140 | CLM-000158 | $2,988.16 | $1,715.44 | $1,714.10 | Paid |
| HRO-000470 | OON | KIPU-000140 | CLM-000159 | $4,673.35 | $2,245.04 | $2,229.29 | Paid |
| HRO-000474 | OON | KIPU-000141 | CLM-000160 | $14,169.76 | $6,488.92 | $0.00 | Pending |
| HRO-000510 | OON | KIPU-000147 | CLM-000167 | $12,923.08 | $5,970.81 | $5,886.94 | Paid |
| HRO-000515 | OON | KIPU-000148 | CLM-000168 | $5,631.76 | $2,489.37 | $0.00 | Pending |
| HRO-000515 | OON | KIPU-000148 | CLM-000169 | $6,081.85 | $3,200.94 | $3,073.64 | Paid |
101 INN claims, 59 OON claims shown above.
Derived from Harbor Ridge Scenario 1's frozen claims and payment
data (harbor_ridge_scenario1.db), via the
deterministic export at
src/data/evidence-trail-251k.json. See also
Evidence for what this category of result
does and does not prove.