Negotiating Payer Contracts In The Fast-Paced World Of Practice Management

Maintaining relationships with payers and validating contracting performance can often take a back seat to day-to-day practice operations. Most offices have never renegotiated their contracts and very few actually renegotiate them on an annual basis or upon contract renewal.

As we discussed earlier this year, revenue pressure can make running a practice difficult for many physicians. Negotiating a managed care contract is one of the most important business moves a physician can make to create a major impact on a practice’s revenue. Therefore, CodeToolz strategically focuses our approach to managed care contracting and negotiations.

We know how to get physicians the competitive terms and rates that, until recently, were only available to the biggest players and networks.

Summary details about the processes we take are below.

Fee Schedule and Reimbursement Analysis

  • Organize, manage and analyze your payer fee schedules in one simple place. All contracts and fee schedules are at your fingertips. (Easy Access)
  • Obtain data downloads for last 12 months of claims and review claim dataset to identify top payers and the most impactful agreements. (Utilization Review)
  • Determine what various reimbursement rates will do to your bottom line, in aggregate and by CPT® code for your payers. (Revenue Impact)
  • Perform reimbursement analysis across spectrum of payers and model against new contract offerings. (Market Analysis)
  • Compare your reimbursements on an ongoing basis; test the adequacy of your charges, test payer offers, your counteroffers and much more. (Effective Negotiations)

The fee schedule and reimbursement analysis is a critical part of the process as it provides us with the insight needed to develop a succinct strategy for renegotiation. We then compare the payer’s fee schedule to current year Medicare and set our goals as to what we expect as a result of our negotiations.

Strategy for Negotiating Payer Contracts

CodeToolz offers physicians managed care contract negotiation services that employ proven contracting strategies, years of experience and the most advanced tools available.

Our strategy is derived from decades of successfully negotiating contracts from the physician and payer side.  Our experience is from both sides of the equation which gives us unique insight into what the payers are looking for and need out of their physician contracts. We provide recommendations for contracting actions based upon data analysis, payer penetration and market knowledge.

Our professional team develops a personalized contracting strategy for every client that fits their unique practice and objectives. We assess each contract and determine if it meets the contracting requirements of our clients.

Once the renegotiation process is nearing completion we will recommend a percentage of Medicare that should be billed out.  This is usually between 150%-200% depending on insurance rates.  Some contracts will pay a percentage of billed charges (although this is rare) so it is important to have your charges at an adequate level to capture all potential revenue.

Successfully negotiating a contract does not happen overnight but the outcome is typically very rewarding.

Full Maintenance and Monitoring of All Contracts

Our ongoing support is intended to emulate the use of an internal managed care department for the practice. We will monitor your contracts using the CodeToolz Contract Analyzer to determine when there is a contract up for renewal.

We will then review, in thorough detail, opportunities for contract renegotiations (increased reimbursements). After review, if there is a potential for a renegotiation, you will be contacted for approval and next steps.


By keeping track of contract negotiation cycles, proactively identifying areas of financial focus, physicians can maximize their reimbursement opportunities as the financial landscape continues to evolve.

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