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.
Discrete Retrospective Audit
Recover Inpatient Underpayments & Revenue Integrity Losses Across Commercial Payers
UnitedHealthcare•Blue Cross Blue Shield•Aetna•Cigna
We provide forensic retrospective audits for independent hospitals. We identify and recover contractually owed revenue that traditional RCM systems mark as "Paid."
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".
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Day 1: Secure Transfer
We sign an NDA. Your team uploads a standard 835/CSV file via our encrypted portal.
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Day 3: Forensic Audit
Our team manually reviews contract logic, outliers, and carve-outs against your fee schedule.
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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.
Engagement governed by NDA prior to data exchange.
Privacy Policy
1. Data Minimization: InpatientRecoveries.com ("Service") adheres to a strict data minimization policy. We do not require direct EMR/EHR access. All audits are performed on specific 835/CSV data extracts provided voluntarily by the Client.
2. HIPAA Compliance: All data transfer occurs via encrypted, HIPAA-compliant channels (AES-256). We act as a Business Associate (BA) under HIPAA regulations and require a signed Business Associate Agreement (BAA) before any PHI is exchanged.
3. Usage of Data: Data provided is used solely for the purpose of identifying contractual underpayments. We do not aggregate, sell, or share hospital data with third parties.
4. Data Retention: Upon completion of the audit or termination of the engagement, all Client data is securely purged from our systems within 30 days.
Terms of Engagement
1. Contingency Model: Our services are performance-based. Fees are due ONLY if we successfully identify and recover underpayments. If no recoveries are identified, no fees are owed.
2. Non-Intrusive Audit: We agree to conduct our review strictly using retrospective data (Closed/Paid Claims). We will not contact patients or interfere with active hospital billing operations.
3. Confidentiality (NDA): A Mutual Non-Disclosure Agreement (NDA) must be executed prior to the release of any detailed pricing or methodology. Both parties agree to protect proprietary information.
4. No Payer Contact: We do not contact payers (UHC, BCBS, etc.) on your behalf without your explicit written approval for each specific batch of claims.
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Contact Audit Team
For audit inquiries, partnership requests, or legal questions, please email us directly.