Payer Contracting & Rate Negotiation

Most provider contracts contain rates that were set once and never revisited, and terms that were accepted without being read. We analyse what you are actually being paid, benchmark it, and negotiate — with the perspective of a team that built and ran managed care organizations before it represented providers.

What is included

• Contract inventory and term analysis — what each agreement actually obligates and permits, including amendment, termination and appeal provisions
• Fee schedule analytics: what you are paid by code, by payer, against benchmarks
• Predictive and comparative fee analysis across commercial, Medicare and Medicaid programs
• Network applications and participation requests, including closed-network appeals
• Rate renegotiation strategy and direct negotiation support
• Managed care contract administration and credentialing coordination
• Single-case and out-of-network agreement negotiation
• Reimbursement modelling for new service lines before you launch them

How the engagement runs

1. Data gathering — contracts, fee schedules and a claims-level extract of what was actually paid, which frequently differs from the contracted rate.
2. Analysis — variance by code and payer, identification of underpayments, and benchmarking against comparable rates.
3. Strategy — which contracts are worth reopening, in what order, and with what leverage.
4. Negotiation — proposal preparation and direct engagement with network management.
5. Implementation — amended rates loaded and verified against subsequent remittances, because a negotiated rate that never gets loaded is worth nothing.

Who this is for

Practices and agencies whose rates have not changed in several years, organizations entering new markets or payer networks, providers who suspect underpayment against contracted terms, and groups preparing for a sale where contract quality drives value.

Frequently asked questions

Can a small practice actually get a rate increase?

Sometimes, and the determining factors are usually not size. What moves a negotiation is network adequacy in your geography and specialty, documented quality or cost data, and whether your request is framed in terms the network manager can take to their own committee. A generic request for more money does not survive that committee.

How do we know if we are being underpaid?

By comparing remittance data line by line against the contracted fee schedule. Underpayment against contracted terms is common and often systematic rather than occasional, and it is recoverable through the contract’s own dispute provisions.

What if the network is closed to our specialty?

A closed network is a starting position, not always a final one. Closed-network appeals rest on demonstrating an access or adequacy gap the plan has an obligation to close.

Related

• Provider Enrollment & Credentialing
• Managed Care Organizations