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Case study · Emergency medicine, go-live diagnostic

ER group go-live: the enrollment playbook behind 245 closed-panel claims

Short answer: a 38-physician ER and hospitalist group went live in August 2026 with 118 of 546 roster lines billable. Enrollment, not coding, caused 55 of the first 79 exceptions and 45 of 46 denials, so the roster became the routing table: every claim is tagged with enrollment status at charge entry and sent down one of three routes.
42 CFR 424.521 · 30-day Medicare look-back 42 CFR 438.602(b) · 120-day pending window Sep 11, 2026 · data cut Diagnostic · found, not yet collected

October 27, 20266 min readASP-RCM Solutions

Archetype
38-physician ER group
Focus
Enrollment at go-live
Metric
118 of 546 billable
Payers
14
Horizon
Aug to Sep 2026
Length
6 min read
546lines
Enrollment roster lines across 38 physicians and 14 payers at go-live
118billable
Roster lines billable on day one, 21.6 percent of the roster
245claims
$85,712 sent to plans whose panels were closed to the group
0vs 55
Coding exceptions versus enrollment exceptions in the first 79

ASP-RCM engagement records

The group and why enrollment, not coding

The roster showed the problem before the denials did

About 38 physicians staffing a hospital emergency department and its inpatient units. The first-four-weeks baseline is published separately.

  1. 1
    Mar 2026Payer enrollment work begins for the group and its physicians
  2. 2
    Aug 2026Professional billing goes live; first claims out August 25
  3. 3
    Sep 11Data cut: 546 roster lines, 118 billable, 245 closed-panel claims
  4. 4
    WeeklyEnrollment-to-revenue pack reviewed with the group every Tuesday
  5. 5
    PendingRemittance-based results, published when they exist

First 79 claim exceptions and first 46 denials by cause, September 11

1,186 claims worth about $410K submitted; 93.3 percent confirmed received by the payer.

Exceptions: enrollment55 of 79, about $19.5K
5569.6% of exceptions
Exceptions: all other causes24 of 79
2430.4%
Exceptions: coding0 of 79
00%
Remittance denials: provider enrollment45 of 46
4597.8% of early denials
Remittance denials: other1 of 46
12.2%
EnrollmentOtherCoding
Takeaway

A coding team at full speed cannot move a claim the payer will deny for enrollment. The roster showed the problem before the denials did, so the roster became the routing table.

The roster as a revenue line

546 lines, 118 billable on day one

Enrollment roster at go-live, 546 lines

Every one of the 428 non-billable lines has a date attached: application filed, contract out for co-signature, or panel confirmed closed. Read as a revenue calendar, those dates say which claims release in which week.

79Effective date in hand, 14.5%
39Local Medicaid plan, no contract needed, 7.1%
6Approved, future effective date, 1.1%
422In process, pending co-signature (78) or panel closed, 77.3%
Billable today: 118 lines, 21.6%Not yet billable: 428 lines, 78.4%
What each status means for a claim

Roster status to claim action

Roster statusCan the claim be paid today?What we do with the claim
EffectiveYesSubmit; monitor the payer acknowledgement
No contract necessaryYesSubmit to the plan's non-contracted emergency path
Approved, future effectiveFrom the effective dateHold to the effective date, then release
In processNot yetHold; date against the enrollment calendar and the 30-day Medicare look-back [1]
Pending contract co-signatureNot yetEscalate the signature; hold the claim
Panel closedOnly as an emergency claimRoute as out-of-network emergency; leadership decides the plan approach

ASP-RCM engagement records

Three routes for submitted claims

Submitted dollars by enrollment route, September 11

$314,608 across three routes

Plan that needs no contract433 claims, submit
$147,85847.0%
Closed-panel plans245 claims, emergency route
$85,71227.2%
Physician still in processhold and date
$81,03825.8%
SubmitEmergency out-of-networkHold

No contract necessary

The largest payer, a local Medicaid plan, pays this service without a contract.

Panel closed

The plan's emergency benefit still applies; worked as out-of-network emergency claims, approach decided per plan.

In process, hard clock

Medicare: bill up to 30 days before the effective date, only when circumstances precluded enrolling in advance [1]. Medicaid managed care: agreement pending screening up to 120 days, then termination if not enrolled [2].

How a claim is routed at charge entry

One question, three exits

At charge entryWhat is this physician's roster status at this payer?
Effective, or no contract necessarySubmit now; monitor the acknowledgement
In process, approved-future, pending co-signatureHold; release on the effective date or inside the look-back
Panel closedRoute as out-of-network emergency; leadership decides the plan approach

ASP-RCM operating method

The playbook

Six steps, run weekly on the group's book

Inventory at the cut: 102 distinct payers; 1,538 of 1,787 accounts were ER visits.

  1. 1

    Build the roster before the first claim

    • Every physician by every payer, with status and the date behind it
    • 546 lines for this group
  2. 2

    Tag each claim at charge entry

    • Roster status at that payer becomes a claim attribute, not a follow-up discovery
  3. 3

    Hold and date in-process claims

    • Against the 30-day Medicare look-back and each plan's pending-agreement window
    • Instead of sending to deny
  4. 4

    Route closed-panel claims as emergency

    • Worked under the plan's emergency benefit as out-of-network claims
    • Leadership decides the approach per plan
  5. 5

    Chase the signatures and the four missing plans

    • 78 roster lines waited on contract co-signature
    • Four plans with 52 claims were not on the roster at all
  6. 6

    Watch submission lag against the calendar

    • Median 14 days from date of service, P90 21 days
    • Unheld claims outrun enrollment dates
What is still open

Status at October 27, 2026

  • 0
    No cash or denial-rate outcomeZero remittance rows had posted at the September 11 cut. Every figure on this page is a go-live diagnostic, not a result.
  • 245
    Closed-panel approachThe per-plan approach for the 245 closed-panel claims is a leadership decision still being made.
  • 78
    Signatures and missing plans78 roster lines pending co-signature and four plans covering 52 claims not yet on the roster.
  • 90d
    90-day follow-upThe remittance-based read of this playbook will be published when the data exists, measured the same way.
FAQ

Frequently asked questions

What is the difference between this page and the first-four-weeks baseline?

The baseline page reports what the September 11 cut measured. This page takes one finding from it, that enrollment caused 55 of 79 exceptions and 45 of 46 denials, and documents the routing method we now run: every claim tagged with the physician's enrollment status at the payer and sent down one of three routes.

Why send a claim to a closed-panel plan at all?

Because the patient was treated in the emergency department and the plan's emergency benefit still applies. Closed-panel claims are worked as out-of-network emergency claims under the plan's own emergency provisions, and the group's leadership decides the approach for each plan. In this group they totaled 245 claims and $85,712 at the four-week mark.

How long can a physician bill before the Medicare enrollment effective date?

Under 42 CFR 424.521, physicians and physician organizations may bill retrospectively for up to 30 days before their effective date, and only if circumstances precluded enrolling in advance. That is why in-process claims are held and dated against the enrollment calendar instead of being sent to deny.

Is there a cash result from this playbook yet?

No. At the September 11 cut no electronic remittances had posted, so there is no collection rate, denial rate or cash figure to report. The routes described here are the method; the measured result will be added when remittances exist.

Sources
  1. 42 CFR 424.521: Request for payment by certain provider and supplier types (govinfo)
  2. 42 CFR 438.602: State responsibilities, screening and enrollment of managed care network providers (govinfo)
  3. CMS: PECOS, the Medicare enrollment system
  4. CMS: Medicare provider enrollment revalidations

Checked October 27, 2026. Rules change; confirm against the source before relying on them. Client figures are archetype aggregates from ASP-RCM engagement records; no client is named.

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