The payer paid less than your contract says it owed. Prove it, per claim.
Underpayment Auditor parses the 835 remittance you already receive, compares each line's paid amount against the expected reimbursement (your contracted rate, or the CMS fee schedule), and hands you a per-claim verdict. Either the payment matches what you were owed, or it does not, and when it does not you get the dollar shortfall, whether it clears the threshold worth fighting, and the recommended next step, as a receipt you can put in front of a payer.
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THE PROBLEM
The 835 lands, the payer says it paid the claim, and you are left with a nagging sense that the number is short. You suspect the payer paid below your contracted rate (a downcoded line, a bundled adjustment that should not have applied, a fee-schedule amount that quietly drifted from what you negotiated), but suspicion is not evidence, and the write-off clock is running. Today this gets caught, if it gets caught at all, by an analyst comparing remittances to contracts in a spreadsheet, line by line, or by a contingency recovery vendor who finds the money and then takes a cut of it. Both are slow, and both leave the systematic underpayments (the ones that repeat quietly across hundreds of low-dollar claims) mostly on the table. The evidence is already in the remittance you receive and the rate you already agreed to. Nobody has just been checking one against the other, deterministically, at the speed the remittance arrives.
HOW IT WORKS
Underpayment Auditor is one composed pattern (AYA-1OPS-RCM-REMITTANCE-PROCESSING-v1) that runs three steps AYA already ships, in one pass:
- Parse the 835. The raw X12 835/ERA remittance is parsed into payments, contractual adjustments, denials, and patient responsibility (AYA-0CAP-RCM-PARSE-835-v1). This is the transaction you get anyway, read into structured lines. - Detect the underpayment. Each line's paid amount is compared against the expected reimbursement from your contracted rate or the CMS fee schedule (AYA-0CAP-RCM-DETECT-UNDERPAYMENT-v1). Shortfalls that clear a configurable threshold (default five percent) come back flagged, with the dollar delta, the percentage, and a recommended action (appeal, contract review, or monitor). The threshold is a data setting, not code, so you tune what is worth chasing. - Age the AR. The resulting outstanding balance is aged (AYA-0CAP-RCM-AGE-AR-v1), so a surfaced underpayment is not just a finding, it is a finding with a clock on it.
No model sits at the point of judgment. The variance is arithmetic against a rate you already hold, which is exactly why the output survives a payer dispute, it is a number anyone can re-derive.
WHAT YOU GET
Per claim, a verdict (paid versus expected), and when the payer underpaid, the exact dollar shortfall, the percentage, and the recommended action, as an auditable receipt. Across a batch, the concentration of underpayment (which payer, which code, which contract line is quietly short at a rate your agreement does not justify), so a repeated systematic underpayment shows up as a pattern, not a stack of individual write-offs. And an appeal-ready variance bundle, so the verdict does not just tell you the payment was short, it hands you what you need to say so. The verdict and the evidence travel together, a conclusion without the receipt does not win a payer dispute, and the receipt without the conclusion is just paper.
WHO IT'S FOR
Provider revenue-cycle teams and payer-contracting managers who know they are being systematically underpaid but cannot prove which claims, billing companies that want an auditable variance engine instead of an analyst eyeballing EOBs, and underpayment-recovery and zero-balance-review shops that want the per-claim receipt without the contingency cut. If you receive 835s and you have a contract or a fee schedule to hold them against, this is built for you.
PRICING (the ladder)
- Pilot. A fixed-price paid proof on your own recent remittance history and your loaded contract rates or fee schedule. You see total underpayment surfaced, per-payer concentration, and per-claim receipts before you commit to anything. - Value-metered. Per remittance batch audited, or a share of documented recovery, once the pilot proves the surfaced number is real and collectible. - Platform. The full parse, detect, and age lifecycle wired behind your billing workflow, every 835 checked against your rates as it arrives.
(Prices are hypotheses we are validating, not commitments carved in stone.)
THE PROOF (the dogfood)
This is not a new engine we are hoping works. The variance math (paid versus expected, delta, threshold, recommended action) is the same underpayment-detection service AYA already carries, and the 835 parse and AR aging are the same services behind AYA's revenue-cycle stack. The product is those three already-built steps composed as one pattern and pointed at your remittance, which took no new business logic. And AYA runs the same discipline on itself, every capability AYA ships terminates as an auditable receipt, the same shape of per-claim proof this product produces. This GTM bundle left one too, the deliverable pattern was quality-scored and its three composed atoms were verified present on disk before this page was written.
HONEST NOTE
A few straight things. First, the auditor is only as good as the rate you give it, expected reimbursement is an input today (your contracted rate or the fee schedule you load), not something it looks up for you, so garbage rates in means garbage variance out, and automatic contract-rate lookup would be a separate build, not part of this. Second, the pattern and the underlying services are real and the deliverable passes our quality gate, but a live run is not one-click yet, the three atom actions still need to be routed to their services in the handler layer (small glue we have named and own, not new logic), and a real paid run waits on a booted mesh, a BAA, and a real 835 export with your rates loaded, so this is capability-ready, not one-click-live for a stranger. Third and to be clear about scope, Underpayment Auditor produces the variance and the receipt, it does not file your appeal, adjust your ledger, or send anything to a payer, that stays your decision and your action.
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*This page is a specification. The capability it describes is not built yet, and nothing here is a claim that it runs today.*