HealOS detects, analyzes, and recovers underpaid claims in real-time using advanced AI trained on payer rules, contract terms, CPT logic, and clinical coding structures. Every payment is validated against expected contract rates, ensuring you never miss a dollar you've earned.
Stop silent revenue leakage. Enforce payer compliance. Recover revenue instantly.
HealOS clients consistently recover revenue that traditional workflows miss.
| Challenge | Impact on Revenue | HealOS Underpayment Detection Solution |
|---|---|---|
| Payments that "look paid" but are incorrect | Silent revenue leakage that grows unnoticed | Real-time reconciliation validates each payment line-by-line |
| Manual staff reviewing EOBs, ERAs, fee schedules | Slow, error-prone audits; missed variances | AI compares paid vs contracted rates instantly |
| Underpayments found after appeal window closes | Permanent, unrecoverable revenue | Real-time alerts ensure timely appeals |
| Complex payer rules, modifiers, carve-outs | Hard to identify mismatches manually | Contract-intelligent AI interprets payer terms with precision |
| No visibility into payer patterns | Systematic underpayments go unnoticed | Machine learning uncovers payer trends & recurring variances |
| Staff bandwidth limits full review | Millions lost annually | Full automation performs 24/7 reconciliation without human labor |
Healthcare teams lose 3–11% of net revenue each year due to underpayments, most of which go completely unnoticed. Manual workflows simply cannot keep up.
Teams scan contracts, EOBs, spreadsheets, and remits line-by-line, leading to inconsistencies and missed discrepancies.
Underpayments often stem from: Modifier issues, Bundled/unbundled CPT errors, Fee schedule mismatches, Payer carve-outs, Incorrect rate escalators. These are nearly impossible to detect manually.
Many variances surface after appeal windows close, permanently turning recoverable revenue into write-offs.
Small discrepancies across thousands of monthly claims $4 here, $18 there, quietly add up to millions lost annually.
HealOS validates every payment against contracted rates the moment ERAs/EOBs arrive. Detect discrepancies instantly, compare expected vs. actual payments, and trigger alerts before deadlines lapse.
AI checks every CPT code, modifier, service line, add-on, bundling rule, and adjustment. Catches underpayments that human reviewers miss. Flags wrong rates, incorrect escalators, and missing add-ons.
HealOS ingests payer contracts using an LLM trained on fee schedules, carve-outs, bundled payment rules, annual rate escalators, and CPT/HCPCS reimbursement variations. Contracts are digitized into a dynamic rules engine for accurate comparisons.
Automatically identifies missing CPT/HCPCS codes, incorrect bundling/unbundling, misapplied payer policies, and rate table variances.
HealOS drafts payer-specific appeals using contract citations, line-item variance reports, payment history, and clinical justification.
Each underpayment generates claim details, expected vs paid amounts, rate tables, contract terms, attachments & supporting documents, ready for instant submission.
ML identifies repeat underpayment patterns, systematic payer issues, high-risk CPT groups, and negotiation priorities.
Claims are ranked by expected recovery amount, likelihood of overturn, timeliness of appeal window, and payer behavior history.
Works seamlessly with Epic, Cerner, Athenahealth, NextGen, eClinicalWorks, Allscripts, DrChrono, 150+ RCM platforms.
End-to-End AI Workflow That Protects Every Dollar of Your Revenue
HealOS uses contract-intelligent AI, real-time reconciliation, and automated appeals to detect, analyze, and recover underpaid claims with unmatched accuracy. Every step is optimized for speed, compliance, and maximum revenue recovery.
HealOS imports and interprets all payer contracts, fee schedules, modifiers, carve-outs, and bundled service rules using a healthcare-trained LLM. What the AI does: Digitizes and normalizes complex contract terms, builds a dynamic, payer-specific rules engine, maps CPT/HCPCS codes, modifiers, escalators, and carve-outs, ensures every future payment is checked against the correct rate.
Incoming ERAs, EOBs, and remittance files are ingested automatically from clearinghouses, billing systems, and EHRs. What the AI does: Captures remits in real time, syncs payments with originating claims, extracts line-level adjudication details.
AI compares paid vs. expected reimbursement for every CPT line, modifier, facility rate, and adjustment. What the AI identifies: Incorrect payment rates, missing add-on codes, bundling/unbundling errors, payer escalator mismatches, carve-out variances.
When variance is detected, HealOS instantly flags the claim and assigns it a priority score based on financial impact, payer behavior patterns, appeal window urgency, and likelihood of successful recovery.
HealOS auto-produces a complete, audit-ready documentation file for each underpayment. Evidence pack includes: Contract term citations, expected vs. paid calculations, historical payment patterns, supporting medical documentation, relevant coding rules.
LLM-powered drafting creates payer-specific appeals in seconds—precise, compliant, and backed by contract evidence. What the AI generates: Reconsideration requests, appeal letters, supporting attachments, contract-based arguments, payer-specific justifications.
HealOS submits appeals and tracks each case across payer portals, IVR systems, and RCM queues. Follow-up automation includes: Status checks, portal updates, documentation resubmission, timely reminders for staff on exceptions.
HealOS learns from every recovered claim to prevent future underpayments. System improves by: Identifying systematic payer trends, flagging risky modifiers or CPT combinations, detecting patterns that cause underpayments, updating internal rules automatically.
Recover lost revenue, ensure contract compliance, and optimize financial performance with intelligent underpayment detection and recovery
Healthcare providers lose 5-8% of total revenue to underpayments, missed charges, and contractual adjustments. AI-powered underpayment detection identifies and recovers this lost revenue automatically, ensuring you capture every dollar you've earned.
Practices that actively challenge underpayments recover an average of $250,000 per year. For a $5 million practice, that translates to up to $400,000 in recovered revenue that would otherwise be lost.
Monitor and compare payments against contract terms in real-time as they're received. Instant detection of discrepancies ensures immediate recovery action, preventing revenue leakage before it compounds.
Eliminate manual underpayment review and recovery processes. AI automatically identifies discrepancies, generates evidence packs, and triggers recovery actions based on payer-specific rules, reducing administrative burden.
Achieve 95% accuracy in identifying payment discrepancies through AI-powered analysis. Machine learning models compare allowed amounts from contracts and fee schedules against ERA/EOB payments with precision.
Ensure payers comply with contract terms and fee schedules. Continuous monitoring identifies systematic underpayment patterns, providing insights for contract renegotiation and payer performance management.
Prevent revenue leakage from underpayments, missed charges, and contractual adjustments. Automated detection and recovery processes ensure you're paid accurately and on time for all services provided.
Accelerate underpayment recovery with automated workflows that prioritize high-value cases. Evidence packs are generated automatically, and appeals are initiated immediately, reducing time-to-recovery significantly.
Gain insights into payer performance and underpayment trends. Detailed analytics identify which payers underpay most frequently, enabling strategic contract negotiations and improved revenue capture.
Built specifically for medical billing and payer rules, not generic automation.
Works with your existing claims, EHR, denial management, and payment systems.
Go live in under 30 minutes using plug-and-play workflows.
95%+ detection accuracy and real-time reconciliation outperform manual workflows.
Get started for $0 – no credit card needed. You'll get up to 20 sessions free.
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