The hidden problem: ‘paid’ doesn’t mean ‘correct’
Clinics often stop at “claim paid.” But payers can underpay due to bundling, edits, incorrect fee schedules, or missing modifiers.
The fix is not to audit everything. It’s to build an exception report and work only the outliers.
The 3‑way match (simple and powerful)
- Expected: what you should receive (contracted/allowed estimate)
- EOB/ERA: what payer says they paid + why adjustments happened
- Deposit: what actually hit the bank
Work only mismatches. This is a “find dollars with less work” system.
Exception report rules (practical)
| Rule | Example | Action |
|---|---|---|
| Paid below threshold | Allowed expected $120, paid $72 | Verify code/modifier; appeal underpayment if appropriate |
| Denied but should be covered | Eligibility denial for active plan | Correct subscriber fields; resubmit |
| Patient responsibility mismatch | Copay higher than plan | Check benefit; correct posting; patient communication |
Operational workflow (weekly)
- Run exception list weekly.
- Pick the top 20 exceptions by dollars.
- Assign owners with due dates.
- Track recovery dollars separately (so the work feels worth it).
Implementation checklist (copy/paste)
- Choose the KPI you want to move.
- Implement one workflow change (SOP + checklist).
- QA sample 10 items/day for 5 days.
- Publish a 1‑page weekly report: KPI, blockers, next action.
Educational resource only — not legal/medical/billing advice.