Unclear Contract Terms Enable Payer Investigations And Allegations of Overpayments

$1,000,000 - $5,000,000 annually through payment hold duration (often 60-180 days), accelerated write-offs of disputed claims, and labor cost of manual dispute resolution (100+ hours per investigation) • $1,000,000 - $5,000,000 per investigation when extrapolation methods are applied to inpatient stays; inpatient cases have higher severity and cost, amplifying impact of each extrapolated finding • $1,000,000 - $5,000,000+ in interim payment holds, operational cash flow disruption

AR Manager manually extracts relevant contract clauses from PDF files; builds response using past dispute examples from institutional memory; email coordination with outside counsel; payment hold tracked in spreadsheet; recoupment amounts reconciled manually in accounting system • AR Manager manually gathers claims data, clinical documentation, and payer communications to build recoupment defense; coordination via email with billing, CDI, and legal; spreadsheets tracking disputed amounts and timelines; verbal escalations to management without formal dispute log • Contract Manager and CDI Specialist attempt to reconstruct payer's interpretation of contract terms from investigation notice; email coordination between clinical and contract teams; manual review of selected claims using inconsistent documentation standards; defense built reactively without pre-established contract interpretation framework