Your facility delivered care. Was the claim paid correctly?
Explore potential gaps between expected reimbursement and actual payer payments. Start with your paid claims, remittance records, and payer contract terms.
For healthcare finance, billing, and revenue cycle teams.
Expected payment
Understand the rates and terms behind each claim.
Actual reimbursement
Compare remittance details with the payment received.
Recovery options
Assess documented differences and applicable deadlines.
A paid claim can still deserve a second look.
An underpayment occurs when a payer’s payment is lower than the amount the provider is entitled to receive under the applicable terms. The starting point is a supported expected payment—not the full billed charge.
A review compares claim details, payer contracts or fee schedules, remittance advice, and payments posted. The goal is to identify discrepancies that warrant further investigation and separate them from valid adjustments.
The path to recovery depends on the payer, contract, claim history, and applicable rules. Begin by defining the claims in scope, the evidence needed, and the available reconsideration or appeal route. A detected variance does not guarantee additional payment.
Understand payment and remittance adviceMatch the payment to the terms behind it.
A useful claims review explains why a payment differs and what documentation supports a correction request.
Rate and contract differences
Compare the applicable reimbursement terms with the rates used to adjudicate the claim.
Payment and adjustment details
Review remittance adjustments, posted payments, and claim-level differences to understand how reimbursement was determined.
Claim history and evidence
Check prior submissions, corrected claims, correspondence, and appeal outcomes before choosing a follow-up action.
Recovery route and timing
Identify payer requirements, contractual deadlines, and supporting documents for any reconsideration or appeal.
Start with your payer mix and revenue cycle goals.
Use the first conversation to describe your facility, billing systems, and reimbursement concerns. Detailed claim data can follow through an agreed secure process.
- Facility type, locations, and payer mix
- Billing or practice management systems in use
- Claims periods and types you want reviewed
- Prior recovery efforts and revenue cycle contacts
From a payment variance to an informed recovery decision.
Define the scope, validate the differences, and agree on the appropriate follow-up.
Define the review
Discuss your facility, target payers, available records, and the claim periods to assess.
Validate the differences
Compare expected and actual payments and check the supporting contract and claim history.
Plan the follow-up
Agree on viable payer requests or appeals, responsibilities, fees, and reporting before recovery work begins.
Questions before you begin?
What healthcare teams should know before starting an underpayment review.
Ask us a questionHow is an underpaid claim different from a denied claim?
A denied claim has not been paid for the denied service. An underpaid claim has a payment that may be lower than the amount due. A claim can contain a mix of paid, denied, and adjusted service lines.
Is every difference from the billed charge recoverable?
No. Contractual allowances, patient responsibility, and other valid adjustments can explain the difference. A review must establish the amount due under the relevant reimbursement terms.
How far back can claims be reviewed?
The review period depends on payer rules, contracts, filing deadlines, and the claim’s history. Discuss the specific payers and service dates before assuming a recovery window.
How will patient information be handled?
Before exchanging protected health information, establish the permitted data use, access controls, secure transfer process, and any required business associate agreement. Initial inquiries should describe the business issue without patient identifiers.
Are recovery amounts, fees, or timelines guaranteed?
No recovery amount or completion date can be established before a review. Confirm the fee model, scope, payer response process, and reporting expectations in the engagement terms.
Take a closer look at the care you’ve already billed.
Talk through your facility’s payment history and where a focused underpayment review could begin.