Why hasn't our primary auditor found these underpayments?

Primary auditors and RCM software typically focus on Coding Accuracy and Denials. They rarely perform a retrospective Contractual Logic Audit on paid claims. We check if the math was right, not just the code.

What data access is required for the audit?

We require Zero System Access. We do not need VPNs or EMR credentials. We work solely from a standard 835/CSV export of paid claims.

Is there a risk of payer recoupment?

Extremely low. We do not upcode or change clinical data. We simply enforce the explicit mathematical terms of your existing payer contract.

Hospital Underpayment Recovery Audit | Inpatient Paid Claims & Contract Variances

We provide retrospective hospital underpayment recovery audits for inpatient claims across major commercial payers. Our forensic methodology identifies paid-claim variances, contract underpayments, zero-balance losses, missed outliers, and implant carve-outs for UnitedHealthcare, Aetna, Cigna, Blue Cross Blue Shield, Humana, and other commercial insurers. We specialize in recovering lost EBITDA for independent hospitals through mathematical validation of closed claims.

Critical Timing

Why Wait? The "Timely Filing" Clock is Ticking.

Commercial payer contracts typically enforce a strict 12-18 month lookback window for underpayment reconsideration. Every month you delay a forensic review, approximately 1/12th of your recoverable revenue expires permanently.

The "Paid" Status Blindspot

Why standard RCM audits miss 1-3% of net inpatient revenue.

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Denials vs. Underpayments

Your RCM team is incentivized to work Zero Pay (Denials). If UnitedHealthcare pays $12k on a $15k claim, the status is marked "Paid" and archived.

The Reality: That $3k variance is not a denial. It is a silent contract misapplication.

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The "Lesser Of" Trap

UHC contracts contain complex "Lesser of Billed vs. Contract" clauses. Standard scrubbing software often defaults to the lower rate without validating if the outlier threshold was met.

The Reality: Automated tools lack the forensic logic to catch multi-variable adjudication errors.

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The Outlier Cliff

High-cost claims often trigger "Outlier" payments. However, if charges are even $1 below the threshold due to a missed charge capture, the entire outlier payment is lost.

The Reality: We identify claims just below the threshold where legitimate charges were omitted.

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Implant Carve-Outs

Many contracts allow for separate reimbursement of high-cost implants (pacemakers, ortho hardware). If the Revenue Code is wrong, the implant is paid at $0 inside the DRG.

The Reality: We find these missing codes and correct them to capture the full payment.

Scope & Operational Boundaries

Our inpatient-only audits apply to UnitedHealthcare, Blue Cross Blue Shield, Aetna, Cigna, Humana, and other commercial payers where paid claims do not reconcile to contractual rates.

What We Validate

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Mathematical Certainty We only review claims where the contractual underpayment can be proven via calculation logic.
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Inpatient Specificity Deep-dive analysis of DRG logic, outliers, and high-cost implant carve-outs.
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Paid Claim Integrity We ensure "Paid" status accurately reflects 100% of the contracted rate.

What We NEVER Do

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No Upcoding We do not alter DRG codes or change clinical documentation.
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No Open AR We do not touch active claims or interfere with your daily billing operations.
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No Mass Appeals We do not flood payers with generic appeals. We submit precise, math-based corrections.

The 7-Day Validation Protocol

A clear, low-friction timeline from "Yes" to "Results".

Day 1: Secure Transfer

We sign an NDA. Your team uploads a standard 835/CSV file via our encrypted portal.

Day 3: Forensic Audit

Our team manually reviews contract logic, outliers, and carve-outs against your fee schedule.

Day 7: Findings Review

We present a line-item report of recoverable cash. You decide if and how to pursue recovery.

Our Promise

Fiduciary alignment. Zero operational risk. We typically identify recoverable underpayments ranging from 0.5%–3% of net inpatient commercial revenue.

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Outcome-Based Engagement

We are compensated only on recovered underpayments. If we find nothing, you owe nothing.

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Zero Operational Lift

Your team provides a limited paid-claim sample. We handle all forensic analysis, validation, and reporting.

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No Payer Risk

No appeals, reconsiderations, or payer outreach occur without your explicit written approval.

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Exit at Any Time

If value is not demonstrated in the preliminary audit, the engagement ends immediately with no cost.

Questions from the C-Suite

Do you only audit UnitedHealthcare claims?

UnitedHealthcare is our initial focus due to the complexity of its inpatient reimbursement logic. However, the same paid-claim forensic methodology applies to other commercial payers where contract underpayment patterns exist.

Why hasn't our primary auditor found this?

Primary auditors and RCM software typically focus on Coding Accuracy (DRG validation) and Denial Management. They rarely perform a retrospective Contractual Logic Audit on paid claims. We don't check if the code was right; we check if the math was right.

What data access do you require? (Safety)

1. Zero System Access: We do not require VPNs, EMR credentials, or HL7 feeds.
2. Paid Claims Only: We do not touch your open AR.
3. Minimum PHI: We only need data necessary for pricing (DRG, Dates, Charges, Payment).

What is the risk of payer recoupment?

Extremely low. We are not upcoding or changing clinical data. We are simply enforcing the mathematical terms of the contract. In cases where the contract math is explicit, the correction is typically straightforward and defensible.

What is the lookback period?

We typically audit claims from the last 12 to 24 months, depending on the timely filing limits specified in your commercial payer contracts (e.g., UnitedHealthcare, BCBS, Aetna). This allows us to recover revenue from closed fiscal periods.

Validate Your Revenue Integrity

We typically begin with a small paid-claim sample to validate recoverability.
Best suited for independent, short-term acute care hospitals with 150–500 beds.

HIPAA Compliant • NDA Provided

Engagement governed by NDA prior to data exchange.

Recover Inpatient Underpayments & Revenue Integrity Losses Across Commercial Payers

Data Ingestion

Variance Identification

Findings Delivery