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Underpayment report

Calderwood Health System · all dates – present · generated Jul 22, 2026
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Total underpayment
$2,015,871
6,898 underpaid lines (8.2%)
Estimated recoverable
$1,310,316
at 65% recovery assumption
Unmatched lines
1,144
no contract on file
Denied lines
0
paid $0

Recommendations

  • Calidon Health Plan accounts for 44 % of total underpayment (¤881,820) — prioritize contract review with this payer.
  • Audit 47562 modifier-LT claims to Corion Health Plan and appeal the short-paid lines.
  • 1,144 service lines had no matching contract — load the missing fee schedules to surface additional recoverable underpayments.
  • Estimated recoverable (¤1,310,316) assumes a 65% recovery rate; adjust to your historical recovery experience.

By payer

Payer detail

PayerLinesVariance%
Calidon Health Plan 3,898 $881,820 44 %
Vantegra Health Plan 1,063 $360,000 18 %
Corion Health Plan 629 $269,351 13 %
Westmark Health Plan 591 $249,989 12 %
Pinehaven Health Plan 552 $215,000 11 %
Medicaid 90 $27,980 1 %
Tricare 40 $9,000 0 %
Medicare 35 $2,732 0 %

Top underpaid CPT codes

CPTUnderpaid linesVariance
27447 668 $584,230
47562 598 $373,592
29881 538 $285,552
49505 440 $173,070
19120 411 $125,724
66984 364 $99,844
45378 272 $54,753
72148 234 $40,747
43239 221 $39,566
73721 207 $34,159
99285 275 $28,964
74177 153 $21,659
64483 134 $19,351
99223 181 $14,383
99205 179 $13,707
93306 82 $10,467
99233 138 $10,283
99284 121 $9,131
99215 120 $8,330
99204 106 $6,748

Variance by adjustment reason (CARC)

diagnostic
CARCReasonLinesVariance
45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement 2,321 $688,764
97 The benefit for this service is included in the payment/allowance for another service 2,277 $671,530
59 Processed based on multiple or concurrent procedure rules 2,300 $655,577

A line can carry several CARCs, so these may sum above the headline total. CO-45 (contractual adjustment) concentrated here often signals a stale contract on file rather than a payer short-pay.

Detected patterns

5 findings
Corion Health Plan · CPT 47562 · modifier LT ModifierGap
Corion Health Plan pays 47562 at 77 % with modifier RT but only 65 % with modifier LT. Review modifier billing and payer adjudication for this combination.
Audit 47562 modifier-LT claims to Corion Health Plan and appeal the short-paid lines.
$8,575
10 claims
Westmark Health Plan · CPT 99285 · modifier 25 ModifierGap
Westmark Health Plan pays 99285 at 90 % with modifier (none) but only 63 % with modifier 25. Review modifier billing and payer adjudication for this combination.
Audit 99285 modifier-25 claims to Westmark Health Plan and appeal the short-paid lines.
$7,070
72 claims
Westmark Health Plan · CPT 99223 · modifier 25 ModifierGap
Westmark Health Plan pays 99223 at 90 % with modifier (none) but only 64 % with modifier 25. Review modifier billing and payer adjudication for this combination.
Audit 99223 modifier-25 claims to Westmark Health Plan and appeal the short-paid lines.
$5,019
69 claims
Westmark Health Plan · CPT 99205 · modifier 25 ModifierGap
Westmark Health Plan pays 99205 at 91 % with modifier (none) but only 64 % with modifier 25. Review modifier billing and payer adjudication for this combination.
Audit 99205 modifier-25 claims to Westmark Health Plan and appeal the short-paid lines.
$4,356
62 claims
Westmark Health Plan · CPT 99233 · modifier 25 ModifierGap
Westmark Health Plan pays 99233 at 90 % with modifier (none) but only 79 % with modifier 25. Review modifier billing and payer adjudication for this combination.
Audit 99233 modifier-25 claims to Westmark Health Plan and appeal the short-paid lines.
$2,211
33 claims