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Payer Contract and Fee Schedule Review
Every paid line priced against your own contracted fee schedule, with the variance by code and payer and the reason each gap opened.
River's payer contract and fee schedule review prices every paid line against the rate your contract actually promises. Send the agreement with its fee schedule attachment and a stretch of payment data. Back comes a sheet holding the expected allowed amount, the amount the payer allowed, and the variance for each code, plus a chart of variance by code and payer. The document beside it separates the gaps worth a recovery letter from the ones worth raising at renewal.
Unlike the contract negotiation checklists that rank for this search, the benchmark here is your own contract rather than the market. Those guides compare your contracted rate against a percentage of Medicare and stop, which tells you whether the rate is good. It cannot tell you whether the rate is being honoured. Those are different questions with different remedies, and the second one is answerable from data you already hold, without a benchmarking subscription or a peer network.
This is for practice managers and revenue cycle leads holding several commercial agreements, administrators preparing for a renewal conversation, and billing companies auditing on a client's behalf. Use it before a renewal window opens, after a payer loads a new fee schedule, or when collections per visit drift with no denial to explain it. A root cause analysis of the denials answers the other half, since a silent underpayment and a denial are different failures.
Why percent of Medicare is not a rate
Most commercial agreements price off Medicare, and most of them do it in a sentence too short to resolve. The physician fee schedule does not publish one number per code. Practice expense is carried at two levels, and the regulation is explicit that facility and nonfacility amounts both exist for most codes, so the same procedure has two Medicare rates depending on where it was performed. A contract naming neither has already left the largest single variance in a fee schedule review undefined.
Then 2026 added a second ambiguity. Beginning that year CMS publishes two conversion factors rather than one, $33.57 for qualifying alternative payment model participants and $33.40 for everyone else. A clause reading current year Medicare Physician Fee Schedule now resolves to two possible dollar amounts per setting, so four per code before geography is applied. Which one the payer loaded is a question about their configuration, and the remittance is the only place it is answered.
Meridian Valley Orthopaedics priced six months against one payer: 1,842 paid lines, 40 codes, $612,400 expected under the attachment, $598,900 allowed. The $13,500 gap looked like 2.2% and therefore like nothing. Four codes carried $12,557 of it. On 20610 alone, 214 lines expected $102.41 and allowed $71.88, which is $6,533, and every one of those lines was performed at a surgery center. The remaining $943 across 36 codes was rounding, and chasing it would have cost more than it returned.
How it works
Send the contract
The payment terms and the fee schedule attachment, however they arrived, as a PDF, a table or pasted text.
Send the payment data
Paid lines for that payer with place of service, modifiers and allowed amounts, from any export you have.
Get the variance sheet
Expected against allowed per line, grouped by code and cause, with the recoverable total named.
Pursue or renegotiate
Send the concentrated gaps as a payer underpayment claim, and take the rest to renewal.
What you get
- Expected allowed amount, actual allowed amount and variance for every paid line
- Variance grouped by code and by payer, so a systematic gap separates from noise
- The likely cause of each gap, from site of service to a fee schedule never reloaded
- The recoverable variance stated in dollars, with the contract provision each claim rests on
- Contract terms that decide the money, quoted back with the clause number and the ambiguity
- The codes worth taking into a renewal conversation, ranked by what they actually earn
Common questions
What if my contract does not include an actual fee schedule?
Many do not, and that is a finding rather than a blocker. Where the agreement only says a percentage of Medicare, the expected amount is derived from that formula and every assumption is written down, including which conversion factor and which practice expense level were used. Those assumptions are exactly what to ask the payer to confirm in writing.
How is this different from comparing my rates to Medicare?
Benchmarking asks whether your rate is competitive. This asks whether the rate you already signed is what arrives. A practice can be at a strong percentage of Medicare on paper and still be underpaid every month because a fee schedule was loaded once and never refreshed, which no benchmark comparison can see.
Can it tell an underpayment from a contractual write-off?
Yes, and that is the line the whole review turns on. An adjustment down to your contracted allowed amount is money the contract gave away, so it is a write-off. An adjustment below that amount is a payment defect. To make the same call across a single remittance file, triage the remittance instead.
How much payment history should I send?
Six months is a good default. That is enough to see whether a gap started on a specific date, which is the strongest evidence that a fee schedule was reloaded or a site of service changed. It is also short enough that most timely filing and dispute windows are still open on the oldest claims in the file.
Will it write the recovery letter for me?
It writes the claim with the contract provision, the rate, the affected lines and the arithmetic, which is the part payers act on. Anything the contract does not actually say stays out of the letter, because a recovery claim that overreaches on one line gets the whole enquiry closed. Your contracting lead sends it.
What if the payer paid the contracted rate but the claim was never sent?
That is a different leak and this review will not see it, because it only prices claims that exist. An encounter that never became a claim leaves no remittance line to compare against anything. A charge capture and coding review reconciles the schedule against the claim file and finds those, aged against the filing deadline.
Does this work for a Medicare Advantage or Medicaid managed care contract?
Yes, with one caution worth knowing up front. Those agreements often reference a state or plan schedule rather than a commercial attachment, so the expected amount depends on the right schedule and version being identified. Where the contract names a source it cannot resolve, the review says so instead of substituting the nearest thing.
Payer Contract and Fee Schedule Review
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