Contract monitoring for provider reimbursement

Every claim should settle to the contract. Underpayments surfaced.

AllCaps checks actual payments against payer fee schedules, carve-outs, stop-loss thresholds, denial rules, and timely-payment terms.

Start with one contract->

Green means the CPT, DRG, carve-out, stop-loss, and payment timing reconcile.

Payer Reimbursement contractsLast checked today, 6:00 AM
4 monitored
2 in line
1 review
1 flagged
Commercial Payer Fee Schedule
E&M and imaging claims reconcile to contracted CPT rates.
In lineMay remits
Implant Carve-Out
High-cost implant claim paid without the 62% invoice-cost carve-out.
FlaggedMay remits
Timely Payment Interest
Late-paid claims identified; interest clock still open.
ReviewMay remits
Stop-Loss Provision
Threshold and paid amount match contract calculation.
In lineMay remits
Who it is for

Built for providers managing reimbursement leakage.

Payer contracts turn into thousands of claim-level calculations. The contract only has value if those calculations are repeated against every remit.

Managed care

Check payer performance against negotiated rates and carve-outs.

Revenue cycle

Prioritize claims where the remittance does not match the expected allowed amount.

Finance

Quantify underpayment exposure by payer, service line, and contract term.

Fee schedules become claim rules

Rates, carve-outs, stop-loss terms, and timely-payment obligations run at claim level.

The contract rate is rarely a single number. It depends on code, modifier, site of service, outlier thresholds, and whether a carve-out applies.

AllCaps calculates the expected allowed amount and compares it to the paid amount, then separates valid variances from recoverable underpayments.

Implant Carve-OutEncoded reimbursement terms
Base rateFee schedule
Implant carve-out62% of invoice
Stop-lossAbove $75k
Interest1.0% / month late
Appeal window180 days
Transactions checked
When the remit is short

The finding shows the claim, the contract term, the expected amount, and the payment gap.

Underpayment work often dies in spreadsheets because the evidence is scattered across contract language, claim data, and remittance detail.

The finding brings those pieces together so recovery can move without rebuilding the calculation.

Finding - Payer Carve-Out - Claim 884219
Implant carve-out omitted from claim payment
Flagged
Expected payment
$18,910
Paid amount
$11,740
Underpayment$7,170
Contract language

Covered implantable devices shall be reimbursed at 62% of documented invoice cost in addition to the base procedure rate when the invoice is submitted with the claim record.

May 2026 remit - Commercial payer orthopedic claimSend to payer->
Across payers

Reimbursement performance belongs in a monitored view.

The roll-up shows clean payers, payers at risk, and claims with documented recovery value.

That makes payer management measurable between negotiation cycles.

In line
11
Review
3
Flagged
2
Commercial payer ACPT fee scheduleIn line
Commercial payer BImplant carve-outFlagged
Medicare Advantage planStop-lossIn line
Timely payment interestPayment timingReview
How it works

Three steps. Then it runs continuously.

01

Encode the agreement

We turn the economic terms in the payer reimbursement agreement into rules: rates, thresholds, caps, credits, formulas, and exceptions.

02

Connect the evidence

Invoices, statements, usage files, claim data, settlement reports, and performance records run against those rules as they arrive.

03

Collect what is owed

Green means in line. Anything else is surfaced with the clause, calculation, period, and counterparty-ready support.

Make one payer contract living and see every claim checked.

We encode the rate schedule, carve-outs, stop-loss, denial, and interest terms, then reconcile recent claims against actual remits.

The first pass
  • One payer agreement or high-volume fee schedule.
  • Claims, remits, CPT/DRG detail, and denial history.
  • Rate, carve-out, stop-loss, and timing rules encoded.
  • Recoverable underpayment findings with claim-level evidence.
Start with one contract->