Reimbursement
Underpayments, downcodes, and the gap between the record and the remittance.
A paid claim is not always a correctly paid claim. This resource center collects the firm’s notes on government and commercial reimbursement: what to compare, which Insights explain a live issue, and when the no-show calculator is only an estimate.
Reviewed by Joseph Rivet, Esq. · October 1, 2026
Start here
The questions this center answers
How Rivet Health Law reads underpayments, downcodes, and fee-schedule changes. Written and reviewed by Joseph Rivet from healthcare operations and reimbursement practice.
Silent fee-schedule and downcoding changes
A commercial policy can reprice a claim without a denial letter. Start with the firm’s note on automatic downcoding.
Learn moreCigna claim downgrades
What a downgrade policy looks like on the next remittance, and why the chart still matters.
Learn moreNo Surprises Act payment disputes
Out-of-network emergency and facility payment questions, including when the statute does not apply.
Learn moreCredentialing that stalls payment
Enrollment timelines can hold a clean claim. The firm’s 2026 note covers the provider–insurer clock.
Learn more
Experience behind this page
Reviewed by Joseph Rivet, Esq.
Founder, Rivet Health Law, PLC
Joseph Rivet spent more than 20 years inside healthcare operations, coding, billing, and reimbursement before practicing law. These notes start from how a claim is built, then from the contract or fee schedule the payor says it used.
Last reviewed October 1, 2026. This page is general information for healthcare organizations. It is not legal advice and does not create an attorney-client relationship.
Who this is for
Who uses this center
- Hospitals and groups reviewing a short allowed amount
- Practices seeing a new downcoding policy on the remittance
- Teams adding a service, site, or device
- Billing companies asked to explain a pattern of underpayments
First pass
First steps you can take today
These steps organize the question. They are not a substitute for counsel.
- 1
Pull five recent remittances that look short and write down the reason codes.
- 2
Match each one to the note, the codes billed, and the contract or CMS schedule.
- 3
Label the shortfall as a denial, a downcode, or a reduced allowed amount.
- 4
If missed visits are part of the leak, run the calculator before changing a patient policy.
Stack the remittance before you argue the number
Most short pays are not dramatic denials. They are a reduced allowed amount, a downcoded visit, a modifier the system ignored, or a fee schedule the plan updated. The useful comparison is the remittance, the contract or CMS schedule, and the note from that date of service.
Appeal windows are often shorter than the time it takes to pull a year of claims. If the remittance is already weeks old, read the timely-filing and appeal language before building a larger sample.
Estimates are not recoveries
The no-show calculator on the tools page estimates lost appointments. It does not decide whether a charge is allowed. A patient policy, the plan contract, and state rules still control.
Counsel for a live underpayment sits on the reimbursement practice page. This center is the reading list and the first comparison, not a demand letter.
Sources
How this page was prepared
Joseph Rivet, Esq. reviews these resource centers. The reading list cites the firm’s own Insights and the public CMS materials those Insights discuss. A newer Insight controls if an older note conflicts with it.
Reading
Insights on this topic
Can an insurance company downcode your claims automatically?
How an edit can reprice a claim before anyone appeals.
Read
New Cigna policy could downgrade your claims without warning
A 2025 commercial downgrade policy and what to look for on the remittance.
Read
Verification of benefits: are payers bound by those calls?
Why a benefit call is not the same document as the contract.
Read
What you need to know about the 2023 Medicare Physician Fee Schedule
How a final rule shows up in the next set of Medicare payments.
Read
More from the archive
Common questions
- Is an underpayment the same as a denial?
- No. A denial refuses the claim. An underpayment pays something, just not the amount the record and the contract appear to support. The evidence and the deadline are often different.
- Does this page tell us what we are owed?
- No. It explains how to compare a remittance with the chart and the published fee schedule or contract. A dollar figure for a specific claim needs the file.
- Where is the no-show calculator?
- It lives on the tools page and at /recovery-calculator/. The result is a planning estimate, not a promise that the practice can bill the patient.
Related counsel
Reimbursement counselDisputes, settlements, and payor adjudication for a live file.OpenOther resource centers
When you want help
Bring the letter, the remittance, or the agreement.
If a note on this page raised a question about your file, the firm can sit with it.
This page is educational. It is not legal advice and does not create an attorney-client relationship. Facts, contracts, and appeal windows control the next step.