Expected pay by code by payer: the table that finds every shortfall

Why 'trust the remit' loses money quietly

A remittance tells you what a payer decided to pay; it doesn't tell you whether that number matches what your contract actually promised. Underpayments — a claim priced against the wrong fee schedule year, a code repriced under an outdated contract, a silent repricing through a network you didn't expect — post as a normal-looking paid amount with no flag attached, unless you're comparing it against something. An expected-payment table is that something: a standing reference of what each code should pay from each payer, checked against the remit as it posts rather than reconstructed after a bad quarter.

What goes in the table

Keep the table narrow enough to maintain: one row per code-payer combination, limited to the codes you actually bill in volume, with the expected allowable and the source you pulled it from sitting side by side so a stale row is obvious the next time you glance at it.

For Medicare, the allowable comes directly from CMS's public Physician Fee Schedule search tool by code and locality 1Ref 1Centers for Medicare & Medicaid Services (2026).Physician Fee Schedule Search.The lookup method for the exact Medicare allowable by code and locality, the source for Medicare rows — no estimation needed, since the tool returns the exact national and locality-adjusted amount along with the RVUs behind it 1Ref 1Centers for Medicare & Medicaid Services (2026).Physician Fee Schedule Search.The lookup method for the exact Medicare allowable by code and locality, the source for Medicare rows2Ref 2Centers for Medicare & Medicaid Services (2026).Physician Fee Schedule.That the Medicare Physician Fee Schedule updates annually, which is why Medicare rows need refreshing on that cadence. For commercial and Medicaid payers, the allowable comes from your signed contract's fee exhibit or the state's published Medicaid fee schedule where applicable.

Where Medicaid rows need their own state source

If you bill Medicaid, pull that state's fee schedule from the state agency directly rather than estimating off Medicare — Florida's AHCA, California's DHCS, New York's eMedNY, and Texas's TMHP each publish current provider fee schedules on their own sites, and Medicaid rates typically diverge meaningfully from Medicare's 3Ref 3Florida Agency for Health Care Administration (2026).Florida Agency for Health Care Administration.Where Florida Medicaid providers find the current state fee schedule for their table's Medicaid rows4Ref 4California Department of Health Care Services (2026).California Department of Health Care Services.Where California Medicaid providers find the current state fee schedule for their table's Medicaid rows5Ref 5New York State Department of Health (2026).eMedNY.Where New York Medicaid providers find the current state fee schedule for their table's Medicaid rows6Ref 6Texas Health and Human Services Commission (2026).Texas Medicaid & Healthcare Partnership (TMHP).Where Texas Medicaid providers find the current state fee schedule for their table's Medicaid rows. A practice billing Medicaid in more than one state keeps a separate row set per state; citing one state's rate for another state's claim is the kind of error the table exists to prevent, not commit.

The reconciliation step: comparing the remit

When a remittance posts, pull the actual paid amount for each line and set it against your table's expected allowable for that code-payer pair. A match closes the line. A mismatch gets one of two treatments: if the remit paid less than expected, that's a candidate for appeal or a payer inquiry — check the CARC/RARC codes on the remit first, since a code like CO-97 (bundled) explains the gap without an appeal, while other reason codes point to a genuine underpayment 7Ref 7X12 (2026).Claim Adjustment Reason Codes.That CARC/RARC codes on a remit explain a payment gap, distinguishing a legitimate reason from a true underpayment. If the remit paid less because your own charge was below the allowable, that's not a payer error — it's a signal your fee schedule needs the annual review, not a claims dispute.

Keeping the table from going stale

The table decays the moment a contract renews, a payer repriced through an unexpected network, or the calendar turns to a new Medicare Physician Fee Schedule year — all of which happen without an announcement that lands on your desk. Tie the Medicare rows to the same annual review where you refresh your own fee schedule, since you're already pulling the current-year PFS lookup for that exercise 1Ref 1Centers for Medicare & Medicaid Services (2026).Physician Fee Schedule Search.The lookup method for the exact Medicare allowable by code and locality, the source for Medicare rows2Ref 2Centers for Medicare & Medicaid Services (2026).Physician Fee Schedule.That the Medicare Physician Fee Schedule updates annually, which is why Medicare rows need refreshing on that cadence. Tie the commercial and Medicaid rows to whenever a contract renewal notice or amendment arrives — update the row the day the new fee exhibit is signed, not when a mismatched remit forces the question.

A minimal version if a full spreadsheet feels like too much

Start with your top 10 codes by volume against your two or three highest-volume payers — that handful of rows catches most of the dollar volume with a fraction of the maintenance. Expand to the full code list only once the habit of checking each remit against the table is established; a 200-row table nobody actually checks against incoming remits does less than a 10-row table that gets checked every week.