Underpayment report

Calderwood Health System · Apr 1, 2025 – Jun 30, 2025 · generated Oct 21, 2026

Total underpayment

$1,506,159

6,055 underpaid lines (6.1%)

Appealable now

claim-level, within the filing window

Lost to time

$1,008,746

was appealable — window has closed

Systematic (Class 2)

$497,413

$323,319 recoverable at 65%

Unmatched lines

1,257

no contract on file

Denied lines

paid $0

Recommendations

Calidon Health Plan accounts for 41 % of total underpayment (¤610,860) — prioritize contract review with this payer.
Audit 99285 modifier-25 claims to Westmark Health Plan and appeal the short-paid lines.
1,257 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; ¤1,008,746 has already aged past the window (recover through monitoring).
Systematic (Class 2) recoverable (¤323,319) assumes a 65% recovery rate on ¤497,413 of contractual shortfall; adjust to your historical experience.

By payer

Payer detail

Payer	Lines	Variance	%
Calidon Health Plan	2,564	$610,860	41 %
Vantegra Health Plan	1,216	$450,588	30 %
Westmark Health Plan	726	$206,691	14 %
Corion Health Plan	661	$118,801	8 %
Pinehaven Health Plan	713	$102,810	7 %
Medicaid	96	$11,094	1 %
Tricare	40	$4,847	0 %
Medicare	39	$467	0 %

Top underpaid CPT codes

CPT	Underpaid lines	Variance
27447	814	$445,297
47562	688	$285,280
29881	650	$230,625
49505	526	$151,702
19120	473	$109,798
66984	422	$88,058
45378	307	$43,605
72148	294	$32,196
43239	243	$28,790
73721	263	$26,868
74177	203	$17,592
64483	119	$10,121
99285	182	$9,282
93306	99	$6,523
62323	64	$4,171
99223	99	$3,932
99205	96	$3,757
70450	55	$2,262
71250	42	$2,214
99233	25	$760

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	2,009	$505,732
59	Processed based on multiple or concurrent procedure rules	2,045	$503,014
45	Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement	2,001	$497,413

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