Across the cycle
The revenue that never shows up in a denial report
Underpayments, fee schedule gaps, missed charges and payer contract performance. Denials are visible because someone said no. This is the money lost quietly, where the claim was paid — just not correctly.
A paid claim is not necessarily a correctly paid claim
Denial management catches the claims a payer refused. It does not catch the claims a payer paid at the wrong rate, the charges that were never captured, or the contract terms that quietly underperform. None of those appear in a denial report, because technically nothing went wrong.
This matters because the administrative cost of running a revenue cycle is already substantial. Billing and insurance-related activities consume around 14.5% of the revenue from a primary care visit and 25.2% of revenue from an emergency department visit (Tseng et al., JAMA, 2018). When margin is that thin, systematic underpayment is not a rounding error.
Payer behaviour has also shifted. Downcoding by automated tools has drawn enough scrutiny that several states — Indiana, Alabama, Utah, Washington, Maryland and Georgia among them — have enacted measures requiring a qualified human rather than an algorithm alone behind adverse determinations. Maryland's insurance regulator found one major payer improperly downcoding evaluation and management claims and ordered it stopped.
- Remittances repriced against your actual contracted rates
- Underpayments identified, documented and pursued
- Fee schedule review against payer contracts and regional benchmarks
- Charge capture audited for services performed but never billed
- Downcoding patterns detected and challenged
- Payer contract performance compared side by side at renewal
- Revenue leakage traced to workflow, not just to claims
How it works
What we actually do
We reprice what you were actually paid
Every remittance is checked against what the contract says should have been paid. The gap between those two numbers is underpayment, and it is invisible unless someone is looking.
We look for what was never billed
Missed charges never reach A/R, never get denied, and never appear in any report — they simply do not exist. Charge capture audit is the only way they surface.
We track downcoding
When a payer systematically pays a lower-level code than what was documented and billed, that is a pattern worth challenging, and increasingly one with regulatory support behind it.
We give you leverage at renewal
Going into a contract negotiation knowing exactly how a payer has performed — denial rate, days to pay, underpayment frequency — changes the conversation.
We report leakage as a system problem
If revenue is leaking through a workflow rather than a claim, the fix belongs in the workflow. We will say so even when it means less claim volume for us to work.
Common questions
What practices ask us about this
How is this different from denial management?
Denial management recovers claims that were refused. Revenue optimization recovers claims that were accepted and underpaid, plus revenue that was never billed at all. Different failure mode, different detection method, different money.
What is a revenue cycle assessment?
A structured review of your current performance — denial patterns, A/R aging, payer mix, charge lag, net collection rate — producing a specific list of what is leaking and what it is worth. It is the usual starting point for a conversation with us.
Do you renegotiate our payer contracts?
We provide the performance analysis that informs negotiation. Whether UnifiedRCM takes part in negotiation directly should be confirmed with them based on your situation.
Will you find anything if our billing is already in good shape?
Often yes, because underpayment detection requires repricing every remittance against contract terms, which almost no practice does at scale in house. If we do not find material leakage, we will say so.
How far back can underpayments be pursued?
That depends on payer contract terms and state law on timely re-review. We identify what is recoverable in your specific situation rather than promising a blanket lookback.
Related services
The rest of the cycle
Find out what your revenue cycle is actually leaving behind.
Request a consultation and a revenue cycle specialist will walk through your denial patterns, A/R aging and payer mix with you. No obligation, and no software to install.