Underpayment report

Calderwood Health System · Jan 1, 2025 – Mar 31, 2025 · generated Oct 21, 2026

Total underpayment

$1,473,842

5,957 underpaid lines (6.2%)

Appealable now

claim-level, within the filing window

Lost to time

$984,086

was appealable — window has closed

Systematic (Class 2)

$489,756

$318,341 recoverable at 65%

Unmatched lines

1,273

no contract on file

Denied lines

paid $0

Recommendations

Calidon Health Plan accounts for 42 % of total underpayment (¤612,681) — prioritize contract review with this payer.
Audit 99285 modifier-25 claims to Westmark Health Plan and appeal the short-paid lines.
1,273 service lines had no matching contract — load the missing fee schedules to surface additional recoverable underpayments.
Appealable (Class 1) — ¤0 still within the filing window, pursued at the full contracted amount; ¤984,086 has already aged past the window (recover through monitoring).
Systematic (Class 2) recoverable (¤318,341) assumes a 65% recovery rate on ¤489,756 of contractual shortfall; adjust to your historical experience.

By payer

Payer detail

Payer	Lines	Variance	%
Calidon Health Plan	2,486	$612,681	42 %
Vantegra Health Plan	1,212	$441,817	30 %
Westmark Health Plan	716	$186,917	13 %
Corion Health Plan	713	$127,682	9 %
Pinehaven Health Plan	636	$87,596	6 %
Medicaid	109	$11,561	1 %
Tricare	47	$5,170	0 %
Medicare	38	$418	0 %

Top underpaid CPT codes

CPT	Underpaid lines	Variance
27447	765	$420,815
47562	706	$287,710
29881	595	$216,024
49505	542	$157,031
19120	476	$111,459
66984	436	$90,886
45378	289	$41,567
72148	289	$31,773
43239	242	$28,302
73721	252	$25,845
74177	186	$15,938
64483	123	$10,715
99285	188	$9,274
99223	128	$5,110
93306	69	$4,596
99205	108	$4,365
62323	55	$3,539
71250	53	$2,769
70450	52	$2,188
99233	26	$790

Variance by adjustment reason (CARC)

diagnostic

CARC	Reason	Lines	Variance
97	The benefit for this service is included in the payment/allowance for another service	2,039	$503,853
45	Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement	1,994	$489,756
59	Processed based on multiple or concurrent procedure rules	1,924	$480,234

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

3 findings

Westmark Health Plan · CPT 99285 · modifier 25 ModifierGap

Westmark Health Plan pays 99285 at 90 % with modifier (none) but only 74 % 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.

$39,603

671 claims

Westmark Health Plan · CPT 99223 · modifier 25 ModifierGap

Westmark Health Plan pays 99223 at 90 % with modifier (none) but only 74 % 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.

$30,870

694 claims

Westmark Health Plan · CPT 99205 · modifier 25 ModifierGap

Westmark Health Plan pays 99205 at 90 % with modifier (none) but only 74 % 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.

$28,998

687 claims