Payment Integrity
Your new rates are signed. Make sure they are being paid.
Payment integrity is a claim-level audit that compares what payers paid against your executed contract rates to find underpayments, loading errors, and missed revenue.
Payers load new fee schedules into their systems by hand, and small errors can run for months without anyone noticing. We check paid claims against your contract terms, so you know exactly what each agreement is delivering.
When a claim pays, it looks like a win. There is no alert when the rate is wrong. A loading error, the wrong locality, or a single phrase in a rate exhibit can trim each payment just enough to go unnoticed. Across thousands of claims, these managed care underpayments add up fast.
The clock is also running. Most payer contracts limit how long you have to dispute an underpayment, often 12 months or less. Errors found late may already be out of reach.
We validate reimbursement against your executed contract and utilization data, one claim line at a time.
We verify that each payer loaded your new fee schedule on time, across every code, location, and provider level.
We flag underpayments, identify the cause, and measure both what has already accrued and what recurs each year.
We show how each agreement performs against what was projected, so you can plan compensation, capacity, and your next negotiation.
You receive a findings report and a working spreadsheet your finance team can review line by line.
Step 1
We need claim-level remittance data or a de-identified extract from your practice management system.
Step 2
After at least three months of claims have paid under the new rates, we typically deliver findings within a month.
Step 3
We walk you through what we found, what it means, and which issues are worth raising with the payer.
A 14-location specialty group asked us to verify four newly renegotiated payer agreements. All four were paying regularly, but our claim-level review found issues no one inside the practice could see.
In that review, Tribunus tested more than 430,000 paid claim lines and found $360,852 a year in recurring underpayments, plus a $236,445 recovery on an underpayment that had run for 19 months.
paid claim lines tested against contracted rates
in recurring revenue at risk each year
recovered on an underpayment that ran 19 months
to complete all four verifications
Results from one client engagement. Recurring amounts are identified and entitled amounts, not guaranteed collections.
Add Payment Integrity to your renegotiation, or ask us about reviewing an agreement you already have.