Matched every billable visit to a remit
Step 1
- Thirteen months of visits against thirteen months of 835s, by patient, date and encounter
- An unpaid visit is a row, not a suspicion
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Case study · FQHC network, payment integrity
Right rate, missing visits: $3.13M of billable visits were never paid
Short answer: the network asked whether it was paid the right PPS rate. It was, 75 to 77 percent of the time exactly. A thirteen-month visit-to-remit match found the gap elsewhere: 9,058 billable visits with no payment, $1.93 million of them closed at $0 with no payer decision.
13 months · Jul 2025 to Jul 2026Visit-to-remit match · 835 by encounter1,737 letters · one claim per patient$180K paid · the only result claimed
Edition
Oct 2026
Archetype
FQHC network
Horizon
13 months
Metric
Visit-to-remit match
Payers
Medicaid · MCOs
Length
5 min read
77%at exact PPS
75 to 77% of Medicaid billable visits paid at exactly the PPS rate; managed care plans at rate 94 to 99% of the time
$3.13Mnot paid
9,058 billable visits with no payment against them, July 2025 to July 2026
$1.93Mclosed at $0
Of those, closed in the practice system with no payer decision; invisible to a denial report
$26,439owed back
True duplicate overpayments across 47 visits, the only money the network owes
From the board's question to the first recovery
After the four-month AR turnaround, the finance committee asked: for every billable visit, were we paid, and were we paid the right rate?
- 1Jul 2025Start of the 13-month date-of-service window
- 2Jul 2026End of the window; every billable visit matched to its 835 by patient, date and encounter
- 3Aug 2026Rate integrity and payment presence split into two reports
- 4Sep 1, 2026Unpaid visits flagged and routed; letters built one claim per patient
- 5Late Sep 2026First 3.5 weeks of recovery measured: about 5%, $180K
- 6OpenPast-deadline decisions and the full recovery result
Rate report
Was the PPS amount right? 75 to 77% exact; plans 94 to 99%
Presence report
Was there a payment at all? 9,058 visits said no
Recovery
1,737 letters; routes by what can still be done
Rate integrityPayment presenceRecovery
Nineteen times in twenty, the payer that paid, paid the right amount
Short payments across the window totaled $592K. The rate engine worked; the problem was the visits never paid at all.
77%
Paid exactly at PPSAll Medicaid billable visits, low end 75%
99%
Plans at rate when paidManaged care plans, low end 94%
$592K
Short-paidReal but not the headline; a separate workstream
47
Duplicate visits$26,439 of true overpayments, being refunded
Payment integrity, three buckets
Unpaid billable visits, July 2025 to July 2026
ASP-RCM engagement records. Because the encounter is paid as one unit, each unpaid visit is a whole-visit loss.$3.13M9,058 visitsNot paidall causes
$1.93M62% of unpaidClosed at $0no payer decision
$592K19% of unpaidShort-paidbelow PPS rate
$26,4390.8%Duplicates47 visits, owed back
Not paid, all causesOf which closed at $0Short-paidOverpaid, refunded
| Bucket | Dollars | Visits | What it is |
|---|---|---|---|
| Not paid | $3.13M | 9,058 | a billable visit with no payment against it |
| Of which closed at $0 | $1.93M | within the 9,058 | closed in the PM system without a payer decision; invisible to a denial report |
| Short-paid | $592K | n/a | paid below the PPS rate |
| Duplicate overpayments | $26,439 | 47 | the only money the network owes back |
The trapA conventional payment-integrity review hunts duplicates and overpayments. Here it would have found $26,439 across 47 visits, and missed $3.13 million. The same whole-visit pattern showed on the denial side in the T1015 denial finding.
Routed by what can still be done, labelled as a ceiling
Unpaid-visit book by recovery route, September 2026
Ceilings, not forecasts. In the first 3.5 weeks after the September 1 flags, about 5 percent, $180K, had paid.
Inside a filing windowappeal or rebill
$1.67M53% of $3.13M
Past the filing deadlinepayer-by-payer decision
$1.11M35%; much will not return
Wraparoundresubmit, no appeal
$323K10%
Medicare Advantage supplementalresubmit
$149K5%
Paid in the first 3.5 weeksmeasured
about $180K5% of the flagged book
$0$0.5M$1.0M$1.5M
WorkablePast deadlineResubmission routesPaid, the only result claimed
| Item | Value | Status |
|---|---|---|
| Letters generated, one claim per patient | 1,737 | achieved built and sent |
| Dollar value at the floor | $587K | the least the letters cover if every one is upheld |
| Paid within 3.5 weeks of the September 1 flags | about $180K, 5% | measured the only recovery figure we claim so far |
| Past-deadline book | $1.11M | open needs a payer-by-payer decision; much of it will not return |
Six moves, in order
Separated rate from presence
Step 2
- Rate integrity and payment presence are two reports
- Mixing them hid the second behind the first
Reopened the $0 closures
Step 3
- Visits closed at $0 with no payer decision became workable claims with a route and an owner
Built one letter per patient
Step 4
- 1,737 letters, each covering one claim
- A payer response tracks to a visit, not a bundle
Routed wrap and supplemental separately
Step 5
- Wraparound and MA supplemental go to resubmission, not appeal, because that is how they are paid
Reported the duplicates too
Step 6
- $26,439 across 47 visits is owed back and being refunded
- Integrity runs in both directions
Takeaway
Were we paid the right rate? is the easy question; in a PPS book the answer is usually yes. Were we paid at all? needs every visit matched to a remit, because a visit closed at $0 never appears on a denial report.
Reported when measured, not before
- 5%The recovery is 5% in, not doneAbout $180K of the flagged book paid in the first 3.5 weeks. The rest is in process and will be reported when measured.
- $1.1M$1.11M is past its filing deadlineSome payers reopen on proof of timely original submission, many do not. Expect write-off on a large share.
- $592KShort payments are a separate workstreamRate variance by payer and site is being reconciled before any underpayment claim is made.
- BHSame-day behavioral-health rules changed what counts as a billable visitThat finding and the county carve-out filing clock are on their own page.
Frequently asked questions
If the PPS rate was right 77% of the time, where was the money?
In visits that were never paid at all. 9,058 billable visits worth $3.13 million had no payment against them, and $1.93 million of that had been closed at $0 in the practice management system with no payer decision. A rate review cannot see those; a visit-to-remit match can.
What does closed at $0 with no payer decision mean?
The visit was marked finished in the practice system with a zero balance, but no remittance, denial or adjustment from the payer explains why. It does not appear on a denial report because nothing was denied. In this network that bucket was $1.93 million across thirteen months of service.
Why call the recovery figures ceilings?
Because $1.67 million inside a filing window, $1.11 million past deadline, $323K of wraparound and $149K of Medicare Advantage supplemental describe what could be recovered if every route succeeds. In the first 3.5 weeks after flagging, about 5 percent, $180K, had paid. That is the only result claimed; the rest is reported when measured.
How big were the duplicate overpayments?
$26,439 across 47 visits, which the network is refunding. A payment-integrity review aimed only at overpayments would have found that figure and missed the $3.13 million of unpaid visits.
- eCFR 42 CFR 405.2463: What constitutes a visit (RHC and FQHC)
- eCFR 42 CFR 447.45: Timely claims payment (Medicaid clean claim definition)
- CMS MLN006397, Federally Qualified Health Center booklet (March 2026)
Ceilings, not forecasts. In the first 3.5 weeks after the September 1 flags, about 5 percent, $180K, had paid.
ServiceFQHC revenue cycle management servicesMatrixFQHC payer matrixGuideFQHC PPS rate guide 2026Case studyThe same network's four-month AR turnaroundCase studyT1015 encounter denials in the first 70 daysCase studyOne encounter, not two: the behavioral-health rulesCase studyFQHC wrap reconciliation case studyBlogHow to fix FQHC wraparound claim denialsWhite paperFQHC revenue cycle management KPI scorecard
Match your visits to your remits
We take thirteen months of encounters and 835s and tell you two things separately: whether the PPS rate was right, and which billable visits were never paid at all.