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28-provider multi-specialty group · Texas · cardiology + ortho + primary care

Systematic underpayments. $1.86M recovered in 12 months.

No fee schedules loaded, so no one saw the payer paying 86 cents on the contracted dollar. A 24-month 835 replay against loaded contracts surfaced the variance, modifier 25/59/GC denials got worked instead of written off, timely filing losses came back with proof-of-submission appeals, and $273K of credentialing-hold claims finally released.

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Setting

Multi-specialty

Providers

Mix

Cards · Ortho · PC

State

Texas

Claims replayed

24 months

Recovered

$1.86M

Result snapshotFour levers. One recovery number.

Contract variance

$842K

PAID BELOW LOADED RATE

Modifier integrity

$418K

25 / 59 / GC OVERTURNED

Timely filing rescue

$327K

80% OF $409K FLAGGED

Credentialing holds

$273K

4 PROVIDERS · 3 PAYERS

$842K + $418K + $327K + $273K = $1.86M TOTAL RECOVERED

Where the dollars came backRecovery waterfall by payer.

PAYERS ANONYMIZED · $612K + $438K + $342K + $274K + $194K = $1.86M

The situationThree leaks. Zero visibility. Every remit trusted.

BASELINE No payer contract loaded in the PM system. Whatever the 835 said got posted. Variance was invisible by design.

Leak 01 · No expected rate

Fee schedules never loaded.

CONTRACTS LOADED

0 of 11

LINES BELOW RATE

18.4%

Leak 02 · Modifiers

25 / 59 / GC denials written off.

MOD-25 DENIAL

14.2%

APPEALED

<5%

Leak 03 · Silent holds

Filing losses and credentialing holds.

TF WRITE-OFFS

$409K

CRED HELD

$273K

None of this is exotic. Commercial contracts in this market are typically written as a percent of the Medicare Physician Fee Schedule, and that reference point moves every year: CMS set the CY2025 PFS conversion factor at $32.35, a 2.83 percent cut from 2024 (cms.gov). When a payer keeps paying against a prior-year schedule, or the group never loads the exhibit at all, the gap compounds quietly. In MGMA Stat polling, a majority of medical group leaders have reported payer denials rising year over year (mgma.com), and unworked modifier denials are a large share of that drift.

Exhibit · contract vs paidEight CPT codes. Same story.

TAKEAWAY High-volume codes carried 5 to 14 percent shortfalls against the loaded contract rate. Small per line, systematic in aggregate.

CPT	DESCRIPTION	CONTRACT RATE	AVG PAID	VARIANCE
93306	Echocardiogram, complete TTE	$228.40	$196.42	−14.0%
20610	Major joint aspiration / injection	$62.80	$54.64	−13.0%
29881	Knee arthroscopy with meniscectomy	$748.20	$665.90	−11.0%
93458	Left heart catheterization	$912.60	$839.59	−8.0%
99203	New patient office visit, level 3	$112.84	$104.38	−7.5%
27447	Total knee arthroplasty	$1,386.00	$1,288.98	−7.0%
99214	Established patient visit, level 4	$131.20	$124.64	−5.0%
99213	Established patient visit, level 3	$92.47	$87.85	−5.0%
VARIANCE LEVER TOTAL · ACROSS ALL FLAGGED LINES, 24 MONTHS				$842K

RATES ILLUSTRATE THE ARCHETYPE PATTERN · ONE COMMERCIAL PAYER SHOWN · VARIANCE = (PAID − CONTRACT) / CONTRACT

The fix · workflowLoad. Replay. Work the variance. Prevent.

RULE Every flagged line carries its lever tag: variance, modifier, filing, or credentialing. Nothing sits in a generic AR bucket.

Modifier integrity · 25 / 59 / GCThe denial heatmap before the fix.

CONTEXT Payers police modifier 25 because misuse is real: an HHS OIG review (OEI-07-03-00470) found 35% of modifier-25 Medicare claims failed program requirements. Clean documentation flips that scrutiny into appeal wins.

Cardiology

Orthopedics

Primary care

Mod 25

15.8%

→ 3.4%

9.6%

→ 2.6%

13.1%

→ 2.9%

Mod 59

9.2%

→ 2.4%

14.6%

→ 3.5%

6.8%

→ 1.9%

Mod GC

7.1%

→ 1.4%

n/a

no residents

9.4%

→ 1.6%

CELL = DENIAL RATE ON LINES CARRYING THE MODIFIER · BASELINE → MONTH 12 · DARKER = WORSE BASELINE

Mod 25 recovered

$201K

E/M + same-day procedure

Mod 59 recovered

$142K

Distinct procedural service

Mod GC recovered

$75K

Teaching physician lines

Modifier lever total

$418K

$201K + $142K + $75K

Timely filing rescue$409K flagged. $327K recovered. 120 days.

A timely filing denial is only final when the claim truly never went out in the window. Most of these had clearinghouse acceptance reports proving submission inside the limit; the payer simply never received or never adjudicated the file. Proof-of-submission appeals reverse those under the contract's own terms. Medicare's filing limit itself is 12 months from date of service under ACA Section 6404 (cms.gov); commercial windows here ran 90 to 180 days.

Credentialing-gap revenue holdsFour providers. Three payers. $273K parked.

Two new cardiologists, one orthopedic PA, and one primary care NP were seeing patients while payer enrollment sat unfinished. Claims either pended, denied, or never went out. Enrollment files were completed and escalated, effective dates were negotiated back to the start-of-service where contracts allowed, and held claims released in batches.

Credentialing hold queue · live refreshed 41s ago

Cardiologist 1Regional Blue plan · enrolled · released

$88K

100%

Cardiologist 2National commercial A · enrolled · released

$76K

100%

Ortho PARegional Blue plan · enrolled · released

$61K

100%

Primary care NPMedicaid MCO · retro window negotiated

$48K

92%

$273K released · avg enrollment gap cut 142 days → 58 days

Engagement ScorecardQuarterly partner report · Q4 redacted

CONFIDENTIAL

KPI movement before vs current.

Lines paid below contract

18.4%

2.1%

Denial rate · all payers

13.9%

7.2%

Net collection rate

91%

96%

Days in AR

54 d

41 d

Modifier-25 denial rate

14.2%

3.1%

Provider enrollment gap

142 d

58 d

Q2 · 2026 ASP-RCM Senior Partner

The 90-Day Plan

How the $1.86M got found.

Days 1-30 · Load and replay. All 11 payer contracts and fee schedule exhibits loaded. 24 months of 835 remits replayed against expected rates. $842K variance flagged and tagged by payer.
Days 31-60 · Modifier and filing queues. Modifier 25/59/GC denial inventory built from CARC/RARC data. Documentation templates fixed at the source. Timely filing evidence packets matched to clearinghouse acceptance reports.
Days 61-90 · Appeals and enrollment. Batched appeals out by payer project. Credentialing files completed for 4 held providers, effective dates negotiated, first hold batches released.
Months 4-12 · Collect and prevent. Overturns and project rebills posted through month 12. Monthly variance replay is now standing. Underpaid-line rate held at 2.1 percent.

ASP-RCM · Senior partner team Recovery posted · monthly cumulative

We assumed the payers paid what the contract said. Nobody had ever checked, because nothing in our system knew what the contract said. Loading the fee schedules changed the argument from opinion to arithmetic.

CEO · multi-specialty physician group

OutcomesBefore. After. In numbers.

Pre-engagement · baseline

Contracts loaded as expected rates

0 of 11

Lines paid below contract

18.4%

Denial rate · all payers

13.9%

Net collection rate

91%

Underpayment leak invisible by design

Month 12 · steady-state

Contracts loaded as expected rates

11 of 11

Lines paid below contract

2.1%

Denial rate · all payers

7.2%

Net collection rate

96%

$1.86M recovered · monthly replay standing

Common questionsFrequently asked: underpayment recovery.

What counts as a payer underpayment?

Any claim line paid below the allowable your contract defines: wrong fee schedule year, wrong conversion factor, a multiple-procedure reduction applied where the contract does not allow it, a bundled line the contract carves out, or a modifier that should have paid separately and did not. Individually these are cents to tens of dollars. Across 24 months of a 28-provider group's claims they added up to $1.86M.

How can you find underpayments if our contracts were never loaded?

That is step one, not an obstacle. We collect every payer contract and fee schedule exhibit, build the expected-reimbursement table by CPT, modifier, and site of service, and then replay 24 months of 835 remittance data against it. The variance engine flags every line where paid is below expected past a tolerance. No expected-rate table means no variance report, which is exactly why the leakage persisted.

Why modifiers 25, 59, and GC specifically?

They are the three highest-friction modifiers for a cardiology, orthopedics, and primary care mix. Modifier 25 covers a significant, separately identifiable E/M on the same day as a procedure and payers deny or down-pay it aggressively; an HHS OIG review (OEI-07-03-00470) found 35 percent of Medicare claims using modifier 25 did not meet program requirements, which is why payers audit it hard and why clean documentation wins appeals. Modifier 59 covers distinct procedural services, common in orthopedics. GC covers services performed in part by a resident under teaching physician direction, which applied to this group's residency-affiliated primary care clinics.

Can timely filing denials really be recovered?

Often, yes. A timely filing denial is only final when the claim was genuinely never submitted in the window. Most of this group's timely filing write-offs had clearinghouse acceptance reports proving original submission inside the limit. An appeal with the acceptance report attached reverses the denial under most contracts. Of $409K flagged as timely-filing loss, $327K, 80 percent, came back. For reference, Medicare's own filing limit is 12 months from date of service under Section 6404 of the ACA (cms.gov).

Why is the client anonymized?

The master service agreement includes reciprocal confidentiality. The figures and timeline reflect the engagement pattern. A senior partner can walk you through methodology and host a reference call under NDA once both sides agree.

What does the free underpayment audit look like?

Send 12 months of 835 remittance files, your payer contracts and fee schedule exhibits, a denial report with CARC and RARC codes, and your provider roster with enrollment effective dates. Inside 30 days you receive a 4-page written audit covering contract-to-payment variance by payer in dollars, modifier denial exposure, timely filing recoverability, credentialing-hold dollars, and a 90-day recovery plan.

Want the same audit run on your remits?

A free 30-day audit. Send 12 months of 835 files, your payer contracts, your denial report with CARC and RARC codes, and your provider roster. We return a 4-page written audit covering contract-to-payment variance in dollars, modifier denial exposure, timely filing recoverability, credentialing-hold dollars, and a 90-day recovery plan. Yours to keep. No SDR follow-up.

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