Underpayment report

Calderwood Health System · Jul 1, 2025 – Sep 30, 2025 · generated Oct 21, 2026

Total underpayment

$1,566,055

6,390 underpaid lines (6.2%)

Appealable now

claim-level, within the filing window

Lost to time

$1,050,868

was appealable — window has closed

Systematic (Class 2)

$515,187

$334,871 recoverable at 65%

Unmatched lines

1,400

no contract on file

Denied lines

paid $0

Recommendations

Calidon Health Plan accounts for 43 % of total underpayment (¤668,505) — prioritize contract review with this payer.
Audit 99285 modifier-25 claims to Westmark Health Plan and appeal the short-paid lines.
1,400 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; ¤1,050,868 has already aged past the window (recover through monitoring).
Systematic (Class 2) recoverable (¤334,871) assumes a 65% recovery rate on ¤515,187 of contractual shortfall; adjust to your historical experience.

By payer

Payer detail

Payer	Lines	Variance	%
Calidon Health Plan	2,730	$668,505	43 %
Vantegra Health Plan	1,331	$484,013	31 %
Westmark Health Plan	607	$156,448	10 %
Corion Health Plan	856	$149,213	10 %
Pinehaven Health Plan	626	$86,578	6 %
Medicaid	131	$14,158	1 %
Tricare	59	$6,389	0 %
Medicare	50	$750	0 %

Top underpaid CPT codes

CPT	Underpaid lines	Variance
27447	792	$439,773
47562	699	$285,959
29881	678	$242,616
49505	551	$160,143
19120	515	$120,721
66984	517	$109,226
45378	329	$47,144
72148	303	$33,293
43239	234	$27,578
73721	255	$25,613
74177	240	$20,797
64483	154	$13,114
99285	191	$9,655
93306	131	$8,403
62323	83	$5,351
99223	117	$4,677
99205	82	$3,305
71250	43	$2,238
70450	46	$1,932
99233	40	$1,098

Variance by adjustment reason (CARC)

diagnostic

CARC	Reason	Lines	Variance
59	Processed based on multiple or concurrent procedure rules	2,157	$526,669
97	The benefit for this service is included in the payment/allowance for another service	2,120	$524,199
45	Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement	2,113	$515,187

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