Underpayment report

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

Total underpayment

$1,785,737

7,244 underpaid lines (6.1%)

Appealable now

claim-level, within the filing window

Lost to time

$1,186,099

was appealable — window has closed

Systematic (Class 2)

$599,638

$389,765 recoverable at 65%

Unmatched lines

1,587

no contract on file

Denied lines

paid $0

Recommendations

Calidon Health Plan accounts for 41 % of total underpayment (¤725,038) — prioritize contract review with this payer.
Audit 99285 modifier-25 claims to Westmark Health Plan and appeal the short-paid lines.
1,587 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; ¤1,186,099 has already aged past the window (recover through monitoring).
Systematic (Class 2) recoverable (¤389,765) assumes a 65% recovery rate on ¤599,638 of contractual shortfall; adjust to your historical experience.

By payer

Payer detail

Payer	Lines	Variance	%
Calidon Health Plan	3,027	$725,038	41 %
Vantegra Health Plan	1,504	$555,409	31 %
Westmark Health Plan	860	$223,484	13 %
Corion Health Plan	895	$162,851	9 %
Pinehaven Health Plan	732	$99,979	6 %
Medicaid	123	$11,696	1 %
Tricare	59	$6,515	0 %
Medicare	44	$765	0 %

Top underpaid CPT codes

CPT	Underpaid lines	Variance
27447	932	$512,143
47562	807	$333,692
29881	767	$278,504
49505	626	$182,280
19120	563	$132,347
66984	518	$107,754
45378	410	$58,030
72148	379	$41,316
73721	320	$32,690
43239	251	$29,624
74177	223	$19,236
64483	145	$12,323
99285	229	$11,404
93306	113	$7,417
99223	164	$6,667
99205	127	$5,062
62323	68	$4,483
71250	69	$3,525
70450	55	$2,266
99233	32	$1,073

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	2,409	$608,565
45	Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement	2,447	$599,638
59	Processed based on multiple or concurrent procedure rules	2,388	$577,534

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