Are payers paying your contracted rates?

Why this is invisible

Every other revenue problem leaves a trace. A denial appears on a denial report. An unworked claim appears on the aging report. An underpayment appears nowhere, because from the system's point of view the claim was paid and closed.

The only way to find it is to compare what was paid against what should have been paid, line by line, against your contracted fee schedule. If nobody is doing that comparison, underpayments are invisible by construction — not hidden, just never looked for.

How it happens

Rarely deliberate. Payer systems are large and fee schedules change.

• Fee schedule updates not applied on the payer side after a contract renegotiation.
• Claims processed under the wrong contract or the wrong plan within a payer.
• Incorrect multiple-procedure reductions applied beyond what the contract specifies.
• Bundling applied where the contract does not call for it.
• Default rates used because the system did not match the provider to the contract.

Each is small on one claim. Across every instance of a common code over a year, the total is usually substantial.

How to check

The manual version

Take your twenty highest-volume CPT codes. For each payer, pull the contracted rate and compare it against what was actually paid on a sample of recent claims. Differences will be obvious immediately.

This takes an afternoon and will tell you whether you have a problem. Most practices doing it for the first time find at least one.

The systematic version

Load contracted rates for every payer and compare every payment at CPT level as remittances post, flagging variances for follow-up. This is what should be happening continuously, and it is the ninth check in the audit framework.

What to do when you find one

• Document the variance — claim, code, contracted rate, paid amount, difference.
• Group by pattern. One claim is an error; the same code underpaid across sixty claims is a systemic issue and a much stronger case.
• Raise it with the payer as a contract matter, not a claim appeal. These are usually handled by provider relations rather than claims.
• Ask for retroactive correction across all affected claims, not just the ones you cited.
• Then check it stays fixed. Corrections are not always applied permanently.

Why this is worth the effort

Unlike aged claims, underpayments have no deadline pressure — but they also do not stop. An uncorrected underpayment on a common code continues on every future claim, which means the cost compounds for as long as nobody checks.

It is also the one check that most billing operations genuinely do not perform, which makes it the most reliable place to find money that nobody is competing for.