Midwest Health System Boosts Collections by Recovering $2.9 Million in Lost Revenue and Strengthens Processes to Prevent Future Underpayments

Key Takeaways

• Leading academic health system engaged Titan’s Zero Balance Audit team to investigate a growing underpayment issue

• Titan uncovered critical CDM configuration and billing logic errors driving systematic revenue loss

• Billing processes were corrected to prevent recurrence and improve long term reimbursement accuracy

• $2.9 million recovered across 970 patient accounts

Overview

The client is a premier integrated academic health system in the Midwest that includes a nationally recognized School of Medicine, 10 hospitals, and a medical staff of more than 4,000 clinicians, including over 1,000 residents and fellows and more than 1,500 employed physicians. Facing mounting concerns around payer reimbursement accuracy, leadership sought an objective assessment to determine both the scale of potential underpayments and the operational changes required to prevent ongoing revenue leakage.

The Challenge

The health system asked Titan to address two urgent priorities. First, quantify the extent of suspected underpayments and recover lost revenue quickly. Second, identify the root cause of the issue and implement corrective actions to prevent future occurrences. Initial internal reviews suggested inconsistencies in reimbursement, but the underlying drivers remained unclear and continued to impact claims performance.

The Solution

Titan’s Zero Balance Audit team conducted a comprehensive review of paid claims, payer contracts, and billing configuration. Analysis of the UHC contract revealed that specific revenue code and CPT code combinations within the Charge Description Master were incompatible with payer reimbursement policies, causing hundreds of claims to be processed incorrectly. Titan determined that when certain revenue codes were billed, facilities were reimbursed only for supporting services such as laboratory work rather than the primary services associated with the visit. UHC classified the primary services as not separately reimbursable when paired with reimbursement methodologies such as per visit, per case, or per unit payments. Titan worked collaboratively with the client to recover revenue while correcting the operational conditions responsible for the issue.

Audit Revealed CDM Configuration Triggered Bundling

The audit confirmed that CDM configuration caused supporting services to be billed using revenue codes that triggered bundling logic, resulting in systematic payment reductions. Titan also identified alternative revenue code options permitted under CMS guidance that allowed appropriate reimbursement.

Correct Revenue Codes Identified and Claims Reprocessed

Using supporting medical documentation, Titan partnered with the Patient Financial Services team to correct impacted revenue codes and resubmit claims. Following rebilling, UHC reimbursed services at the intended contractual rates.

Collaborative CDM Optimization

Titan worked directly with the health system’s CDM team to isolate the CPT and revenue code combinations responsible for payment errors. Updated configurations were implemented, including the addition of appropriate revenue codes designed to prevent future underpayments while improving billing accuracy and reducing ongoing manual intervention.

The Results

Through a coordinated effort, Titan helped the health system recover significant lost revenue while implementing durable process improvements. The organization achieved immediate financial recovery and established safeguards that reduce future reimbursement risk.

By the Numbers

$2.9 Million recovered in underpayments across 970 patient accounts.