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Underpayment report

Calderwood Health System · Oct 1, 2025 – Dec 31, 2025 · generated Oct 21, 2026
Total underpayment
$1,658,005
6,717 underpaid lines (6.0%)
Appealable now
$0
claim-level, within the filing window
Lost to time
$1,120,544
was appealable — window has closed
Systematic (Class 2)
$537,460
$349,349 recoverable at 65%
Unmatched lines
1,500
no contract on file
Denied lines
0
paid $0

Recommendations

  • Calidon Health Plan accounts for 39 % of total underpayment (¤647,510) — prioritize contract review with this payer.
  • Audit 99285 modifier-25 claims to Westmark Health Plan and appeal the short-paid lines.
  • 1,500 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; ¤1,120,544 has already aged past the window (recover through monitoring).
  • Systematic (Class 2) recoverable (¤349,349) assumes a 65% recovery rate on ¤537,460 of contractual shortfall; adjust to your historical experience.

By payer

Payer detail

PayerLinesVariance%
Calidon Health Plan 2,703 $647,510 39 %
Vantegra Health Plan 1,338 $500,592 30 %
Westmark Health Plan 844 $224,832 14 %
Corion Health Plan 860 $153,337 9 %
Pinehaven Health Plan 750 $109,749 7 %
Medicaid 115 $12,693 1 %
Tricare 64 $8,534 1 %
Medicare 43 $758 0 %

Top underpaid CPT codes

CPTUnderpaid linesVariance
27447 895 $489,307
47562 767 $310,914
29881 722 $256,356
49505 593 $171,369
19120 528 $122,598
66984 436 $90,390
45378 348 $49,804
72148 336 $36,711
73721 285 $29,254
43239 237 $27,925
74177 238 $20,511
99285 241 $12,137
64483 122 $10,387
93306 95 $6,253
99223 137 $5,577
62323 75 $4,857
99205 113 $4,289
71250 60 $3,187
70450 45 $1,824
99233 29 $878

Variance by adjustment reason (CARC)

diagnostic
CARCReasonLinesVariance
97 The benefit for this service is included in the payment/allowance for another service 2,268 $565,518
59 Processed based on multiple or concurrent procedure rules 2,258 $555,026
45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement 2,191 $537,460

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