# A clean, paid, closed claim can still be short of the contract By Elizabeth Venafro · Published 2026-11-06 · Healthcare on MarketScale Canonical: https://www.marketscale.com/industries/healthcare/a-clean-paid-closed-claim-can-still-be-short-of-the-contract Creator hub: RSK > Take an orthopedic case with two claims. The billing team coded them, billed them and posted the payments. By the rules that team works under, both claims were handled correctly. That still doesn't mean the practice got paid what its contract says it's owed. ## Key points - Correctly coded and billed healthcare claims can still result in underpayment. - Practices should review closed-claim payments against contract terms to spot underpayments. - Discrepancies in claim payments can persist despite adherence to billing protocols. Take an orthopedic case with two claims. The billing team coded them, billed them and posted the payments. By the rules that team works under, both claims were handled correctly. That still doesn't mean the practice got paid what its contract says it's owed. That's the argument behind treating underpayment recovery as its own job. In this view, the money gets lost in "the gap nobody owns, the space between what the contract says and what the payer's system actually paid." For orthopedic practices, surgery centers, MSOs and health systems, the question is who is responsible for checking that gap, and whether anyone already in the revenue cycle is set up to do it. ## Why a correctly billed claim can still come up short Billing work has a defined finish line. A claim is coded, submitted and posted, and if it isn't denied, it's done. Underpayment sits past that line. The payer's adjudication system applies its own reading of the fee schedule, and what it pays may not match the negotiated terms. A claim can be clean, paid and closed and still be short. That's why the speaker calls it the gap "nobody owns." Coding staff have no reason to look at it. Denials teams don't either, because nothing was denied. Payment posters record what came in, not what should have come in. Each function did its own job correctly, and the shortfall falls between them. Block Field ## A separate job, not a rival to billing Because it's aimed at a different problem, the speaker describes contract-level payment review as "fully complementary" to internal billing staff, external RCM vendors and the third parties that may already handle work for an orthopedic practice, surgery center, MSO or health system. The speaker calls it "a separate process with a separate job." The speaker also spells out where that job stops. It doesn't involve recoding claims or retouching clinical documentation, and it "shouldn't compete with your RCM vendor or denials team." That boundary matters to a revenue cycle leader. Bringing in another party is easier to justify when it doesn't reopen questions about coding accuracy or leave the current vendor feeling second-guessed. Sometimes the review turns up a real billing error instead of a payer-side variance. In that case, the finding goes back to the billing team with the specifics, so they can fix it at the source. The speaker calls these "great learnings" and "good corrections." Handled this way, the review gives the existing team feedback it wouldn't otherwise get, and the fix stays with the people who own the process. - In scope: comparing paid amounts on closed claims against contract terms and fee schedules, payer by payer. - Out of scope: recoding, changing clinical documentation, or taking over denials management. - Handoff: true billing errors go back to the billing team with specifics so they can correct them at the source. ## Start with closed claims, then keep checking The work starts where billing ends, with claims that are already closed. The speaker describes a 24-month look back on a practice's top payers, or across its whole payer mix, to show "how each payer actually behaves." The historical pass is meant to surface patterns as well as one-off shortfalls. If a payer's system keeps paying a certain service below the contracted rate, that shows up across many claims, not just one. After the look back, the same check runs going forward. The speaker ties this directly to timing: running it continuously means "findings get worked well inside the timely filing windows." Timely filing limits are payer-set deadlines that cap how long a provider has to act on a claim. A variance found after the window closes may be impossible to recover. A one-time audit can find old money, but only an ongoing review keeps new shortfalls from aging out. Block Field ## Why billing teams weren't built for this The speaker's case comes from running a physician group that provided care at large senior living communities in major metro areas. In that role, the speaker managed the group's payer contracts and fee schedules directly. That makes the account of the gap a firsthand one: the person who owned the contracts still couldn't check payments against them. "We just didn't have time to check payment at this level of detail against the contract," the speaker said. The group relied on the billing module in its Athena EHR and a few in-house staff to cover RCM basics. That setup handled claims. It wasn't built to check every payment against negotiated terms. > It's just a different niche job than billing teams are built for today. — Former physician group operator, on contract-level payment review Any group running a similar setup, with an EHR billing module, a small internal team and perhaps an outside vendor, could end up with the same split. The person who knows the contract terms is often an executive with other priorities, and the people closest to the claims don't track contract rates. The speaker's point isn't that these teams are failing. They're staffed and measured for something else. ## The ownership question for practice and health system leaders For leaders at orthopedic practices, surgery centers, MSOs and health systems, the argument comes down to who owns the comparison. If no role is explicitly responsible for checking paid amounts against contracted amounts, that check probably isn't happening, however well billing and denials perform on their own measures. These are the speaker's claims about how the approach is built, not independently verified results, and the source doesn't say how often payers underpay or by how much. The reasoning still gives leaders a way to test their own operation: 1. Is anyone checking closed claims against the contract, payer by payer? 2. Do confirmed billing errors go back to the billing team for correction at the source? 3. Does the review run often enough to act inside timely filing windows? If the answer to the first question is no, billing can be done right and the money can still come up short. Tags: healthcare post --- Source: MarketScale, https://www.marketscale.com/industries/healthcare/a-clean-paid-closed-claim-can-still-be-short-of-the-contract. Published for AI indexing and citation; cite the canonical URL. Site guide for agents: https://www.marketscale.com/llms.txt