Hospitals and health systems routinely receive less than what their payer contracts entitle them to. A forensic look-back of the last 12–24 months of remittance files against actual contract terms typically uncovers recoverable underpayments in the 5–10% range — identified and collected within a 6–9 month window, on a pure contingency basis.
Request a Free Opportunity Assessment →Most health systems assume that if a claim was paid, it was paid correctly. That assumption is expensive.
Payer contracts are dense, frequently amended, and rarely reconciled at the line-item level after adjudication. Carve-outs, stop-loss thresholds, fee-schedule updates, multiple-procedure adjustments, and modifier-driven reductions create dozens of ways an individual claim can be paid below contract. Each one, viewed in isolation, looks like a routine adjustment. Across 12–24 months of remittance volume, the same patterns compound into millions of dollars left on the table.
Internal billing teams are typically focused on current AR and active denials — not on auditing remittances that already cleared. Outsourced RCM partners apply the same forward-looking lens. Look-back recovery is structurally different work, and it requires a structurally different engagement.
From data collection to collected funds — here’s what the engagement actually looks like.
Once data flow is established in the first 30–60 days, recovery work runs continuously through resolution. Most engagements collect the bulk of recoverable funds within nine months of kickoff.
Everything from data collection through collected funds is included in the contingency arrangement.
Outsourced RCM and underpayment forensic recovery are complementary, not redundant. RCM handles current billing operations — submitting claims, working denials, managing AR going forward. Underpayment recovery is a one-time, deep look at remittances that already cleared, reconciled against contracts that may have been amended multiple times since the date of service.
Most health systems run both at once. The forensic work recovers historical dollars that the current operation was never structured to find, while the RCM operation continues to manage everything moving forward. There is no overlap in scope and no contention over claims.
If you already have a strong RCM operation, this engagement is additive, not duplicative. If you don’t, the forensic look-back can run in parallel with an RCM evaluation.
A 20–30 minute conversation is all it takes to scope the assessment. If there’s no meaningful opportunity, we’ll tell you. If there is, the assessment quantifies it before you commit to anything.
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