Multi-specialty group · 6 payers · 2 quarters
Three vendors missed it. We found 4.1% of net revenue.
Underpayments are not denials. They post as paid and close, so a denial-first vendor never sees them. ASP-RCM loaded expected reimbursement against every contract, ran paid-versus-allowed-versus-contracted variance on 835 files, and appealed the breaches by clause. Systematic variance surfaced across four payers.
Setting
Multi-Specialty
Providers
64
Payers audited
6 commercial
Engagement
2 quarters
Prior vendors
3
Net patient rev
$118M
Result snapshotThe four numbers that moved.
Net revenue recovered
4.1%
2-QUARTER CUMULATIVE
Underpaid claim lines
7.8%
OF ALL PAID LINES
Appeal win rate
81%
CLAUSE-CITED APPEALS
Group profile
64-prov
MULTI-SPECIALTY · 6 PAYERS
The signature viewPaid vs allowed vs contracted.
READ THIS
The gap between the blue bar and the gold line is the underpayment. A denial vendor only sees paid. We model contracted.
The situationPaid claims. Below contract. Invisible to denial work.
BASELINE
Three prior vendors worked denials. None loaded expected reimbursement. 7.8% of paid lines were sitting below contract, unseen.
Cause 01 · Fee schedule
Fee schedules not loaded.
PAYERS LOADED
0 / 6
EXPECTED $
None
Cause 02 · Downgrades
Downgrade and bundling leakage.
E/M DOWNGRADE
6.4%
BUNDLED LINES
3.1%
Cause 03 · Clauses
Contract clauses never read.
CARVE-OUTS
Missed
TIMELY FILE
At risk
The method · workflowLoad expected. Compare to 835. Appeal by clause.
RULE
No variance flagged without the contract clause behind it. Lesser-of payments are filtered out before appeal.
What the dashboard showsVariance queue by payer. Paid, contracted, and gap.
GREEN
Paid on contract
AMBER
Variance under review
RED
Timely-filing risk
Variance queue · 6 payers · live
refreshed 19s ago
Payer CFee-schedule variance · -22% · aged 51d
$412K
96%
Payer AE/M downgrade · -16% · aged 33d
$318K
88%
Payer DBundling leakage · -12% · aged 28d
$204K
76%
Payer BFee-schedule variance · -9% · aged 14d
$186K
58%
Payer FCarve-out re-price · -7% · aged 11d
$122K
47%
Payer ABundling leakage · -14% · aged 26d
$98K
72%
Payer ELesser-of · paid correct · closed
$0
OK
Payer DFee-schedule variance · -10% · aged 9d
$77K
41%
$1.42M in appeal · 1 red · 3 amber · 1 lesser-of filtered
Underpayment ScorecardQuarterly partner report · redacted
CONFIDENTIAL
KPI movement before vs current.
Expected reimbursement loaded
0 / 6
6 / 6
Underpaid lines detected
0.0%
7.8%
Avg paid-vs-contracted variance
unknown
-14%
Appeal win rate · clause-cited
n/a
81%
Net revenue recovered
0.0%
4.1%
Timely-filing at-risk claims
18.2%
1.4%
Q2 · 2026
ASP-RCM Senior Partner
The recovery rampTwo quarters. From zero to 4.1%.
We assumed a paid claim was a closed claim. Three vendors told us the same thing. The first variance report showed us money we had already written off as collected. It was sitting under the contract the whole time.
CFO · multi-specialty group
State changeHow the paid book actually looked.
BEFORE
Denial-only · no expected model
- Zero of six fee schedules loaded
- Paid claims treated as final and closed
- E/M downgrades never re-priced
- Contract clauses unread before appeal
- Timely-filing risk on 18.2% of claims
AFTER
Expected loaded · variance appealed
- All six fee schedules loaded and live
- 835 variance run at every posting
- Downgrades and bundling flagged and appealed
- Appeals cite the exact contract clause
- Timely-filing risk down to 1.4%
Where the recovery came fromTop CPT codes by underpayment recovered.
TAKEAWAY
High-volume E/M and procedural codes carried the variance. Paid held below the contracted rate on every line below.
| CPT | DESCRIPTION | PAID | CONTRACTED | VARIANCE | RECOVERED |
|---|---|---|---|---|---|
| 99215 | Office visit, established, high complexity | $168 | $204 | -18% | $214,000 |
| 99214 | Office visit, established, moderate complexity | $118 | $137 | -14% | $186,000 |
| 45378 | Colonoscopy, diagnostic | $402 | $511 | -21% | $158,000 |
| 93000 | Electrocardiogram, complete | $21 | $28 | -25% | $121,000 |
| 20610 | Arthrocentesis, major joint | $74 | $92 | -20% | $103,000 |
| 99223 | Initial hospital care, high complexity | $188 | $219 | -14% | $94,000 |
| 36415 | Collection of venous blood, venipuncture | $3.10 | $4.20 | -26% | $71,000 |
| 76942 | Ultrasonic guidance, needle placement | $96 | $121 | -21% | $58,000 |
| TOP 8 SUBTOTAL · 72% of recovery | -19% avg | $1.01M | |||
835 analysis · productivityWhat loading expected did to the desk.
835 lines modeled
100%
Was 0% modeled
Variance flag TAT
24h
At posting, not months
Appeal win rate
81%
Clause-cited appeals
Timely-filing at risk
1.4%
Was 18.2%
Implementation13 weeks. Four checkpoints.
ENGAGEMENT PROFILE
DURATION
2 quarters
GROUP
64-prov
NET REV RECOVERED
4.1%
CHECKPOINTS
4
W1 · LOAD
Load the contracts.
All six fee schedules and contract rates loaded. Expected reimbursement modeled per CPT.
W4 · VARIANCE
First 835 variance run.
Paid vs allowed vs contracted compared line by line. 7.8% of paid lines under contract.
W7 · APPEALS
Appeal by clause.
Lesser-of filtered. Underpaid claims appealed with the exact contract citation and 835 line.
W13 · RECOVERED
4.1% recovered.
Cumulative across two quarters. 81% appeal win. Load kept live so new variance is caught at posting.
Capability stackWhat the variance engine actually runs on.
NOT
A denial work queue
IS
Expected-reimbursement model
COMPARES
Paid vs allowed vs contracted
EVERY APPEAL
Cites the contract clause
Layer 04 · AI
AI Suite · Variance detection · Downgrade flag · Appeal drafting
▼
Layer 03 · LLM Gateway
Single audited choke point · cost meter · prompt registry
▼
Layer 02 · Platform
Reporting Cloud · expected-reimbursement engine · 835 parser
▼
Layer 01 · HIPAA-eligible AWS
AES-256-GCM PHI · row-level RBAC · PHI access log
Common questionsFrequently asked: underpayment recovery.
What is a payer underpayment?
A payer underpayment is the gap between what a claim was contracted to pay and what the payer actually allowed. It is not a denial. The claim adjudicates, posts, and closes as paid, so it never lands in a denial work queue. The only way to catch it is to model the expected reimbursement from the loaded contract rate and compare it line by line against the 835 remittance. If you do not load expected reimbursement, you cannot see the variance.
Why did three prior vendors miss the underpayments?
Because they worked denials, not variance. Prior vendors chased zero-pay and partial-denial claims where the payer said no. Underpayments are paid claims that adjudicated below the contracted rate. Without expected-reimbursement modeling loaded against each fee schedule, a paid claim looks finished. The money was hiding in claims that everyone had already marked as resolved.
What frameworks drive the recovery?
Contract-rate loading and expected-reimbursement modeling, paid-versus-allowed-versus-contracted variance analysis, fee-schedule variance detection, downgrade and bundling leakage review, 835 remittance analysis at the service-line level, and appeals of underpaid claims that cite the specific contract clause. Reading the contract itself matters: timely-filing windows, lesser-of language, and carve-outs decide which variances are recoverable.
What is lesser-of language and why does it matter?
Lesser-of clauses say the payer will reimburse the lower of billed charges or the contracted rate. When billed charges fall below the fee schedule on a given code, the payer pays the lower billed amount, which is correct under the contract. Flagging those as underpayments wastes appeal effort. Reading the clause first separates true variance from contractually correct lesser-of payments, so appeals only go out where the contract was actually breached.
How fast does recovery show up?
The first variance report lands inside 30 days once expected reimbursement is loaded and 835 files are parsed. Appeal filing starts in week four. Cash on recovered underpayments follows the payer appeal cycle, typically 45 to 90 days per payer. The 4.1% of net revenue figure is cumulative across the first two quarters.
Why anonymize the client?
The engagement includes reciprocal confidentiality. The numbers, frameworks, and timeline are real for the archetype. A senior partner can walk you through methodology and arrange a reference call under NDA once both sides agree.
What does the free underpayment audit include?
Send your payer contracts or fee schedules, 90 days of 835 remittance files, and your top 25 CPT codes by volume. Inside 30 days you receive a written audit covering paid-versus-allowed-versus-contracted variance by payer, downgrade and bundling leakage, fee-schedule load gaps, recoverable dollars, and an appeal plan by clause. Yours to keep.
Want the same audit applied to your paid claims?
A free 30-day underpayment audit. Send your payer contracts or fee schedules, 90 days of 835 remittance files, and your top 25 CPT codes by volume. We return a written audit covering paid-versus-allowed-versus-contracted variance by payer, downgrade and bundling leakage, fee-schedule load gaps, recoverable dollars, and an appeal plan by clause. Yours to keep. No SDR follow-up.