Zorva for family medicine
For the 5–20-physician family-medicine practice with a dedicated billing desk. The high-volume claim shape is the one Zorva is calibrated against.
Why Zorva is calibrated for family medicine
The v12 prompt was trained on a 19-encounter, 31-gold-finding val set that is mostly family medicine. The audit rules that fire most often — modifier-25 unlock, CMGP, referring-NPI for the lab / specialist referral pattern — are family-medicine patterns. Zorva's recall on these is meaningfully higher than its aggregate F1 would suggest.
The 7 highest-yield rules for family-medicine practices are listed below. Every one of them is a pattern a family-medicine biller sees on real claims every week.
The 7 highest-yield rules for family medicine
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Modifier-25 unlock
When a procedure and an E/M visit are billed on the same day, the E/M needs a -25 modifier. Without it, AHCIP bundles the visit into the procedure and pays $0. Family-medicine clinics that do in-office procedures (joint injections, biopsies, IUDs) leave real money on the table here.
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CMGP on same-day GP + procedure
A GP performing a procedure same-day as a visit should declare CMGP. Without it, the visit line pays 50%. Family-medicine volume makes this the single highest-yield rule on a per-month basis.
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Referring NPI for specialist referral
Specialist visit billed but the clinical note mentions a referring provider. AHCIP denies with 80G if the referring_provider_npi is missing. Easy to miss because the referring NPI is not on the clinic's own claim — it's on the receiving specialist's claim. Zorva flags when the clinical note suggests a referral pattern.
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Lab coverage
Lab billed without an AHCIP-eligible diagnosis pointer. Common in family medicine because in-house lab is high-volume and the diagnosis- pointer field is easy to miss. Zorva flags when a lab is billed but no HI segment carries an AHCIP-eligible code.
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After-hours premium
Visits billed outside the standard 9–5 window without the after-hours premium code. Common in walk-in components of family-medicine practices. Zorva flags when the service time suggests an after-hours premium is missing.
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Preventive opportunity (AWV / HMV)
Patient eligible for a preventive service (AWV, HMV, well-baby) that wasn't billed. Zorva flags when the patient is age-eligible and there's no AWV / HMV code in the last 12 months.
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Duplicate service
Same procedure billed twice in a 30-day window for the same patient. Zorva flags when the diagnosis and the procedure are identical across two claims inside the rolling window. The clinic may not realize one was a duplicate.
What this is worth on the biller's desk
A 5–10-physician family-medicine practice submitting 3,000–5,000 AHCIP claims per month will see roughly 800–1,500 findings per month from the auditor. Of those, the biller accepts 600–1,200 (about 75% are real findings) and dismisses 200–300.
The per-finding dollar impact varies widely — modifier-25 unlock is about $50 per claim, CMGP is about $85, referring NPI is about $45. The total recoverable monthly revenue for a 4,000-claim practice is in the range of CAD $30,000–$80,000.
Run the numbers on your own claim shape with the ROI calculator or send 100 of your own claims and we'll send a 1-page report.
A worked example
50-year-old patient with established hypertension and a new sore shoulder. The biller billed a 99213 (level-3 established-patient office visit) and a 20610 (major joint injection, shoulder). The auditor flagged 3 things:
- Referring NPI missing on the specialist referral (~$45 impact, AHCIP 80G)
- CMGP not declared on the same-day GP + procedure (~$85 impact, AHCIP GR 4.4)
- Modifier-25 not appended on the separately- identifiable E/M (~$50 impact, AHCIP GR 1.4)
Open the sample claim to see the full audit, the rule citations, and the quote from the clinical note.