Healthcare and life sciences / Managed BPO
Payer underpayment review for commercial medical claims
Actigy BPO reviews claims that a commercial payer has already paid. We compare the allowed amount on the remittance with the amount expected under your approved rate rules. Your revenue cycle team gets a line-level worklist with the supporting evidence, questions for the contract owner and recommended follow-up.
Agree the scope, access and reviewer before a paid pilot.
- Expected allowance
- $150
- Remittance allowance
- $130
- Payer / patient split
- $105 payer + $25 patient
- Possible allowance variance
- $20, subject to contract review
A worked example of the record and decision flow. Not a client case or promised result.
The work. The handoff. Your decision.
A defined workflow in your systems
For provider revenue cycle teams and billing companies with posted remittances, access to the applicable payer agreements and a finance owner who can resolve disputed rate interpretations.
You provide
Paid claim, remittance and client-approved fee schedule.
Actigy BPO prepares
Line-level allowance comparison and evidence for follow-up.
You retain
Rate interpretation, recovery action and approval.
Decision owner: Revenue cycle and contract owner. Confirm this role and the escalation contact in the written scope.
Service detail / 01
Which paid claims should you send for review?
Start with one commercial payer, product, provider group and service period. The review needs the claim line, remittance, contract or fee schedule, effective date and any relevant adjustment or patient responsibility. Missing rate versions go on a separate worklist so they do not inflate the underpayment total.
- Payment posting records what a payer sent. This review checks whether a paid line used the expected allowance.
- A fully denied line belongs with denial management. A paid line with a lower allowance than expected belongs in the variance queue.
Worked example
How do you distinguish an underpayment from patient responsibility?
The approved fee schedule lists a $150 allowance. The remittance shows a $130 allowance, split between a $105 payer payment and $25 owed by the patient. The possible allowance difference is $20. Comparing $150 to $105 would also count the patient’s share. The reviewer checks the applicable rate version, modifier and adjustments before classifying an underpayment.
Service detail / 03
What will your contract owner receive?
Each exception records the rate source, service date, expected allowance, payer allowance, difference, evidence reference and next owner. The reviewer distinguishes a documented discrepancy from a line where two contract terms could apply. Your contract owner decides the interpretation and whether to challenge the payment.
- Group related discrepancies by payer, plan, code or rate version so the owner can spot a recurring pattern.
- Keep confirmed variances, requests awaiting payer response and additional cash posted as separate totals.
Service detail / 04
What happens after the client approves a variance?
Actigy BPO prepares the reconsideration packet or follow-up worklist in the agreed system. Your team approves payer contact, any formal submission, adjustment or write-off. A favorable payer response stays open until the additional remittance can be matched to the claim and finance confirms the posting.
Service detail / 05
How do we scope the first paid review?
Choose a representative group of paid lines and keep suspected underpayments in a separately labeled sample. Agree the rate source, permitted reviewer locations and escalation owner. Report lines compared, items awaiting contract interpretation, confirmed shortfalls and extra payments actually posted. A dollar identified for review counts as recovered only after the additional payment is received and matched.
Before the first live queue
Bring the inputs that shape your scope
The proposal should identify what can be assigned, who can decide, and how you will accept the work. Start with one representative queue; agree any expansion after reviewing the pilot.
Define the workload
Service dates, rate versions, payer mix and adjustment codes.
Agree the controls
Expected-allowance method and exclusions approved by the contract owner.
Review the right measures
Proposed differences, confirmed shortfalls and additional payments posted.
Before you decide
Buyer questions
Clarify the work, access and approval boundaries before assigning a team.
Do we have to move our billing system?
We can scope review inside your approved revenue cycle tools or use a controlled export. Identify the available remittance and contract records, access limits and permitted work locations before sharing claim data.
What if the payer contract is ambiguous?
We document the affected lines, effective dates and competing interpretations. The contract owner confirms the rule before an amount is classified as an underpayment.
Can a billing company use the service for its own provider clients?
Yes. Agree the provider and payer permissions, who approves each packet, how you want the worklist labeled and who handles payer communications.
How is the engagement priced?
The quote depends on payer contracts, rate complexity, claim-line volume, exception rate and follow-up scope. A paid sample measures the work required. An identified variance becomes recovered cash only after the additional payment is received and matched.
Review a payer variance sample
Give the payer mix, size of the paid-claim queue and who handles contract interpretation. Leave claims, remittances and patient details out of the form.
Your inquiry
Payer underpayment review
Describe the workload and the decision owner. Keep confidential records out of the form; agree a suitable channel for any later sample.
- Review the fitWe review the workflow and the inputs you provide.
- Define the scopeDiscuss access, coverage, review and the proposed fee.
- Agree a paid pilotApprove the written scope before work begins.