ClaimLift

Idea

A self-serve tool that gets small independent physician groups paid the money federal arbitrators are already awarding out-of-network claims, without giving up a third of it to a contingency vendor. ClaimLift screens each out-of-network claim for federal No Surprises Act arbitration (IDR) eligibility, estimates the likely payout against published CMS determination benchmarks, and auto-generates the Open Negotiation and IDR filing paperwork. It is built for emergency medicine, anesthesiology, and radiology groups too small for a white-glove vendor to prioritize.

Market gap

Providers win the large majority of federal IDR disputes and often recover several times the insurer's original payment, but the process is dominated by a handful of private-equity-backed mega groups. Independent physicians largely sit it out, not because the odds are bad but because determining eligibility and preparing a filing requires legal-level judgment (federal vs. state law, plan type, notice and consent history, timely filing windows) that a small practice's billing staff does not have.

The only real help today is full-service, contingency-fee vendors like HaloMD, which are built to take over the whole dispute end to end and keep a cut of every award. That is the right fit for practices happy to hand off the whole relationship. It is the wrong fit for a small group that wants to file its own claims and keep the money, but cannot justify the labor to build the legal-eligibility logic and paperwork templates in-house.

Timing is right now for three reasons. First, CMS just cut the per-dispute administrative fee from $115 to $15, a rule explicitly aimed at expanding access for smaller providers, which was previously priced out of disputing lower-value claims. Second, the IDR backlog that made filing a multi-month gamble is closing: closures roughly matched new filings in the most recent CMS reporting window. Third, AMA's own 2025 benchmark data shows nearly half of anesthesiologists and radiologists, and a third of emergency physicians, are still in private practice, meaning tens of thousands of physicians sit outside the PE-backed groups already running this playbook at scale.

Total Addressable Market (TAM)

Bottom-up, from physician workforce counts and private-practice share:

• US professionally active physicians (KFF/AAMC data, May 2026): Emergency Medicine 67,617; Anesthesiology 56,410; Diagnostic Radiology 49,001.
• Private-practice share (AMA Physician Practice Benchmark Report, May 2025): Emergency Medicine 33.2%, Anesthesiology 46.4%, Radiology 46.9%.
• Independent physicians in these three specialties: EM 22,449 + Anesthesiology 26,174 + Radiology 22,981 = approximately 71,600.
• Assumption: independent groups in these hospital-based specialties average roughly 10 physicians per group (staffing a handful of hospital or facility contracts). That yields approximately 7,160 independent groups.
• Assumption: a flat blended subscription across claim-volume tiers averages $500 a month, or $6,000 a year per group.

TAM = 7,160 groups x $6,000/year = approximately $43,000,000.

SAM: assume roughly 60% of independent groups are not already locked into a full-service RCM or contingency vendor that bundles IDR filing (the remaining 40% are already served or indifferent). SAM = 4,296 groups x $6,000 = approximately $25,800,000.

SOM: a realistic 3-year capture of 3% of SAM = roughly 129 groups x $6,000 = approximately $774,000 ARR. That is the initial beachhead, not the ceiling: expanding into adjacent out-of-network-heavy specialties (neonatology, pathology, hospitalist medicine) later widens the base well beyond these three.

Monetization strategy

Flat monthly SaaS subscription per practice, tiered by monthly claim volume, billed to the group (not per physician). The practice pays whether or not a given claim wins, which is the opposite of the contingency model and is the point: a group that files its own claims keeps 100% of every award instead of splitting it with a vendor. Retention comes from the deadline tracker and paperwork generator becoming the system a billing manager checks weekly, and from the compounding revenue proof (dashboard showing cumulative dollars recovered) that makes the subscription self-evidently worth renewing.

Pricing strategy

• Starter, $199/month: up to 15 claims a month. Entry point for a small single-hospital-contract group.
• Growth, $499/month: up to 50 claims a month. The anchor tier, priced for a multi-site group.
• Scale, $999/month: up to 150 claims a month, plus priority support and CSV batch import.
• Overage: $15 per claim above the tier cap, matched to the new CMS administrative fee so the pricing story is easy to explain. No claim-based percentage fee at any tier. That absence is the entire pitch relative to contingency vendors.

Lead magnet

A free, no-signup "IDR Eligibility & Payout Estimator." A billing manager pastes in a claim's payer, plan type, state, service date, and QPA vs. billed amount, and gets an instant read: eligible or not for federal IDR, plus an estimated payout range built from published CMS specialty benchmarks (for example, radiology claims have recently settled at a median of roughly 600% of the QPA). It proves the tool's core judgment call in under a minute and makes the size of the money left on the table concrete.

Competitors

• HaloMD: the largest independent filer of IDR disputes for physician groups. Full-service, contingency-fee ("we don't get paid until you get paid"), positioned as a technology-enabled service partner, not self-serve software. Serves practices ranging from small to large but the relationship is a handoff, not a tool the practice's own staff drives.
• iMPROve Health: operates as a Certified IDR Entity (the neutral arbitrator), not a provider-side filing tool. Relevant as part of the ecosystem, not a direct competitor.
• Right Medical Billing / MyHealthcareBilling and similar RCM outsourcers: bundle IDR filing as one line item inside a full revenue-cycle-management outsourcing contract. Requires handing over the whole billing relationship, not just the dispute workflow.
• Brault: medical billing and coding company that partners with HaloMD to offer IDR services to its existing outsourced-billing clients, another full-handoff bundle.

What competitors offer now

Every current option is full-service: identify the claim, determine eligibility, prepare the filing, negotiate, and collect a cut of the result. None of them sell a flat-priced tool a practice's own billing manager operates independently. That is by design for a contingency business (the vendor wants control of the whole claim to make money) but it leaves a specific customer unserved: a small group that has the staff time to file its own claims and just needs the legal-eligibility logic, the benchmark data, and the paperwork automated, without giving up 100% control or a share of the award.

What can be done differently to attract customers

Charge a flat subscription instead of a contingency percentage, so a group that recovers well keeps all of it. Lead with a free, no-signup eligibility and payout estimator that proves the tool's judgment before asking for a credit card, the same instant-value pattern that converts in every other vertical-SaaS lead magnet. Target the CMS fee cut (from $115 to $15) directly in marketing and content: it is a real, dated regulatory event that makes previously uneconomical small claims worth disputing for the first time, giving a concrete reason to sign up now rather than "eventually."