Underpayment report

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

Total underpayment

$1,820,032

7,413 underpaid lines (6.2%)

Appealable now

$195,344

claim-level, within the filing window

Lost to time

$1,003,509

was appealable — window has closed

Systematic (Class 2)

$621,180

$403,767 recoverable at 65%

Unmatched lines

1,572

no contract on file

Denied lines

paid $0

Recommendations

Calidon Health Plan accounts for 41 % of total underpayment (¤745,456) — prioritize contract review with this payer.
Audit 99285 modifier-25 claims to Westmark Health Plan and appeal the short-paid lines.
1,572 service lines had no matching contract — load the missing fee schedules to surface additional recoverable underpayments.
Appealable (Class 1) — ¤195,344 still within the filing window, pursued at the full contracted amount; ¤1,003,509 has already aged past the window (recover through monitoring).
Systematic (Class 2) recoverable (¤403,767) assumes a 65% recovery rate on ¤621,180 of contractual shortfall; adjust to your historical experience.

By payer

Payer detail

Payer	Lines	Variance	%
Calidon Health Plan	3,055	$745,456	41 %
Vantegra Health Plan	1,403	$510,968	28 %
Westmark Health Plan	963	$252,028	14 %
Corion Health Plan	932	$169,960	9 %
Pinehaven Health Plan	818	$120,682	7 %
Medicaid	134	$16,214	1 %
Tricare	42	$4,098	0 %
Medicare	66	$625	0 %

Top underpaid CPT codes

CPT	Underpaid lines	Variance
27447	958	$523,996
47562	879	$357,304
29881	798	$282,863
49505	620	$178,610
19120	593	$138,717
66984	480	$99,953
45378	368	$52,453
72148	354	$38,692
73721	315	$32,041
43239	271	$31,689
74177	240	$20,667
64483	169	$14,605
99285	232	$11,738
93306	116	$7,507
99223	163	$6,809
99205	145	$5,790
62323	82	$5,259
71250	68	$3,593
70450	62	$2,600
99233	38	$1,094

Variance by adjustment reason (CARC)

diagnostic

CARC	Reason	Lines	Variance
45	Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement	2,547	$621,180
97	The benefit for this service is included in the payment/allowance for another service	2,483	$602,176
59	Processed based on multiple or concurrent procedure rules	2,383	$596,676

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