Underpayment report

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

Total underpayment

$1,672,346

6,752 underpaid lines (5.2%)

Appealable now

$1,091,621

claim-level, within the filing window

Lost to time

was appealable — window has closed

Systematic (Class 2)

$580,725

$377,471 recoverable at 65%

Unmatched lines

1,378

no contract on file

Denied lines

paid $0

Recommendations

Calidon Health Plan accounts for 42 % of total underpayment (¤698,227) — prioritize contract review with this payer.
Audit 99285 modifier-25 claims to Westmark Health Plan and appeal the short-paid lines.
1,378 service lines had no matching contract — load the missing fee schedules to surface additional recoverable underpayments.
Appealable (Class 1) — ¤1,091,621 still within the filing window, pursued at the full contracted amount; ¤0 has already aged past the window (recover through monitoring).
Systematic (Class 2) recoverable (¤377,471) assumes a 65% recovery rate on ¤580,725 of contractual shortfall; adjust to your historical experience.

By payer

Payer detail

Payer	Lines	Variance	%
Calidon Health Plan	2,920	$698,227	42 %
Vantegra Health Plan	1,460	$531,937	32 %
Westmark Health Plan	733	$190,399	11 %
Corion Health Plan	744	$137,482	8 %
Pinehaven Health Plan	673	$96,161	6 %
Medicaid	113	$10,619	1 %
Tricare	60	$6,929	0 %
Medicare	49	$592	0 %

Top underpaid CPT codes

CPT	Underpaid lines	Variance
27447	855	$474,215
47562	763	$311,483
29881	710	$254,267
49505	598	$173,131
19120	566	$132,961
66984	508	$105,758
45378	341	$48,722
72148	346	$37,750
43239	282	$32,882
73721	269	$27,699
74177	257	$22,272
64483	154	$13,287
99285	199	$10,102
93306	93	$6,338
99223	120	$4,834
99205	108	$4,339
62323	65	$4,210
71250	43	$2,232
70450	41	$1,673
99233	34	$913

Variance by adjustment reason (CARC)

diagnostic

CARC	Reason	Lines	Variance
45	Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement	2,304	$580,725
97	The benefit for this service is included in the payment/allowance for another service	2,242	$559,143
59	Processed based on multiple or concurrent procedure rules	2,206	$532,478

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