A Virginia Mental Health Group Was Underpaid $143,000 by Two Payers. They Never Filed a Single Dispute.
Table of Contents
THE SITUATION
8 licensed therapists. Stable patient base. Clean claim submission process; first-pass acceptance consistently above 90%. No obvious billing problems. Revenue was coming in, A/R was manageable, and the practice owner wasn’t looking for anything wrong.
We were brought in to do a routine annual RCM review. Standard scope: denial rate, A/R aging, collection ratio.
Within the first week, the ERA audit flagged something the denial reports never would have: Anthem BCBS VA and Optum were paying below contracted rates on four CPT codes 90837, 90847, 90853, and 90791 across all eight providers. The claims were being paid and posting to the ledger. No denial. No flag. No one looking.
WHAT WAS ACTUALLY WRONG
We pulled the current signed contracts for both payers and built a CPT-level fee schedule comparison against 24 months of 835 ERA data.
Anthem BCBS VA was paying 90837 at $128 when the contracted rate was $147. A $19 gap per claim. At 340 units of 90837 per month across eight providers, this was a $6,460 monthly underpayment, $77,500 annually on one code with one payer.
Optum was paying 90847 (family therapy with patient) at the 90846 rate (family therapy without patient). The difference: $22–$31 per claim. Optum’s system had the two codes mapped identically in their fee schedule, a payer-side configuration error affecting every 90847 claim the practice submitted.
90791 intake assessments were underpaid by Anthem at $163 vs. contracted $194. Intakes are high-volume at a growing practice. Thirty-one dollars per intake, 40+ intakes per month: $1,240/month lost, invisible without a contract comparison.
WHAT WE DID
Week 1: Built a complete contract-to-ERA comparison at the CPT code level for both payers. Documented every underpaid claim with the contract reference, paid amount, contracted amount, and variance. Produced a formal underpayment dispute letter for each payer.
Week 2: Submitted Anthem dispute with 24 months of 90837 and 90791 underpayment documentation. Anthem’s dispute process requires a formal letter, contract reference, and claim-level detail; we provided all three.
Week 3: Contacted Optum provider relations directly regarding the 90847/90846 mapping error. Framed it as a payer-side configuration issue rather than a billing dispute. Optum corrected their fee schedule mapping within 10 days and processed corrected payments for 18 months of underpaid claims.
Weeks 4–12: Anthem processed the dispute and issued corrected payments for 20 months of 90837 and 90791 claims within the dispute window.
THE RESULTS
| Payer | Code | Underpayment/Claim | Total Recovered |
|---|---|---|---|
| Anthem BCBS VA | 90837 | $19 | $77,500 |
| Anthem BCBS VA | 90791 | $31 | $18,600 |
| Optum/UHC | 90847 | $22–$31 | $21,900 |
| Total | $118,000 | ||
$118,000 recovered in 90 days. $25,000 fell outside dispute windows and was not recoverable. Going forward: monthly ERA-to-contract reconciliation catches any new variance within 30 days.
WHAT THIS MEANS FOR YOUR PRACTICE
Underpayments are the revenue leak practices never find because they look like successful billing. If you’re not comparing actual paid amounts against contracted rates by CPT code at least quarterly, you’re likely being underpaid somewhere and collecting nothing on it.