First, use your PayerIntel access to conduct a comprehensive audit of the published payment rates. By comparing your own payment data for specific CPT codes with the payments received by other practices, you can quickly identify areas where you are being underpaid for the very same CPT codes.

Second, identify the CPT codes and payers where the discrepancy between your own payments and the market average presents the greatest disparity and revenue opportunity.

​Last, use this data to develop a negotiation strategy.  Armed with valuable data, you can confidently approach payers with the facts based on actual data. Your PayerIntel access provides irrefutable evidence of potential underpayment for your services provided to their members- allowing you to present a clear and compelling case for increased payment rates.

Payer contract renegotiation is not just limited to payment rates. You may want to consider credentialing requirements, termination clauses, unfavorable terms, and other contract terms MCO’s often unilaterally impose on your practice. 

​Regardless of other contract terms in your contract that you may need to address, payment rates are generally the main focus of the Managed Care Organization (MCO) negotiation and with your newfound data, a powerful starting point.

​Historically when practices negotiate with payers, they fly blind as they are limited to only comparing rates between existing contracts. With PayerIntel access, now you can compare how you're paid against other providers and organizations. This unprecedented level of transparency significantly enhances your negotiating leverage with MCOs.

Most practices typically wait to analyze data and negotiate their rates at the time of contract renewal. But with access to critical data and added leverage, renegotiating your rates is something you should consider doing whenever the data points to a disparity that is impacting your practice’s financial stability. 

​No matter when you determine the right time to renegotiate - whether it’s at contract renewal or mid-contract - renegotiation doesn’t have to be daunting.

The basic steps to negotiate better rates with an MCO include Measure, Compare, Negotiate, Decide, and Monitor. PayerIntel data will help you with the first few steps: Measure and Compare. But moving on to negotiating fair payment rates gets a little trickier. Here’s where to start:

Step 1: Research

Using the PayerIntel portal, research and identify the top 5-10 CPT codes out of alignment.

Step 2: Calculate the revenue impact.

Keep it simple. An example of this is: your audit indicates you can increase 99213 (office visit) or 90460 (vaccine admin) by $5, and if you administer two thousand of these a year, then you could earn $10k more in revenue. 

Step 3: Make The Ask

Reach out to your payer contractor, present your top areas of rate misalignment, and ask if they can be adjusted to align with the market value. 

​If they say yes, congratulations! Wrap up your new rates as quickly as possible. If they say no, you will need to decide the best way to proceed. You have a couple of options:

1. Wait until your contract renews. If you go this route, you still want to have your research done and your desired terms identified. 
2. Terminate your current contract terms. This does not sever your relationship with the payer - just your current terms. Make it clear that you do not want to leave but that the rates are not in line with what you should get paid and that is the driver for this decision. The step of sending a termination notice can be scary.  However, it is not unusual for payers to insist on this option as a way to keep practices from requesting appropriate rate adjustments during the contract term- usually two to three years long.

Step 4: Document Everything

• MCO’s have very little, if any, incentive to respond to your requests.  Depending on their market position, they know that your practice is dependent on access to their members in order to remain in business.  As such, MCO’s will often be very slow to respond- which is part of their negotiation strategy.  
• ​Maintaining an accurate account of your interactions with the MCO’s it will provide the information you need if you have to get your state Insurance Commissioner’s Office involved.

Step 5: Final Review Before Signing

It is vitally important that you carefully review anything offered by an MCO for your signature.  There are often specific phrases and terms within the contract that may have a significant impact on your practice’s financial/operational performance.

Depending on the length of the contract and the impact a given MCO has on your financials, practices should consider seeking legal counsel before signing such documents.  Contracts offered by MCO’s are packed with legalese that carry varied meanings that generally favor the MCO.  An experienced attorney can help you understand the meaning behind the jargon.