Created for behavioral-health operators using practical revenue-cycle experience. It provides general business education—not billing, legal, clinical, insurance, coding, or compliance advice.
Define the expected amount
For contracted services, the expected amount should be based on the applicable agreement, fee schedule, payment methodology, code, modifier, provider, place of service, and date. For other reimbursement arrangements, document the basis for the expectation and its limitations.
Avoid using billed charges as the only benchmark. The difference between charges and payment is not automatically an underpayment.
Create a variance worklist
Compare expected reimbursement with allowed amount, payer payment, patient responsibility, and adjustments. Establish a materiality threshold so the team focuses on variances worth investigating.
Group potential underpayments by payer, plan, code, level of care, adjustment reason, and service month. Recurring patterns are often more actionable than isolated claims.
Validate before escalating
Confirm eligibility, network status, authorization, coding, claim data, coordination of benefits, and contract terms. Determine whether the payer applied a deductible or coinsurance correctly and whether another payment or reversal exists.
Maintain the evidence supporting each request: claim, remittance, applicable terms, expected calculation, previous correspondence, and a concise explanation of the variance.
Measure the program
Track identified variance dollars, validated underpayments, disputed dollars, recovered dollars, average resolution time, and recurrence after correction. Separate one-time recoveries from ongoing payment improvements.
Use the findings to improve expected-reimbursement logic and executive forecasting. A recovery program is most valuable when it also makes future revenue more predictable.
Find your clearest next step.
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