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Analyzing your payer contracts


When was the last time your practice looked at your contracts with payers? Do you have the entire contract, or just the signature page?  Many practices find the contract review process complex and overwhelming. Yet understanding how you are being reimbursed, and why you may not be getting a full reimbursement for the services you provide helps your practice identify crucial issues.
Practices are encouraged to find the fully executed contracts for their top ten payers and compare reimbursement, per CPT, for the top 25 CPT codes for each payer. This allows you to compare reimbursement by payer and current Medicare rates. Is one payer paying less than most payers for some of your most frequently billed CPT codes or are they denying the service which requires your practice to appeal?  While the analysis may take some time (especially if you are not using a business analytics tool which can do much of the work for you with specific reports), there can be significant value to finding missed opportunities.

Working with your clearinghouse, practices also need to analyze the denial rate for each payer. Using the overall denial rate, compare across all payers. Identify specific CPT codes that are being denied - identify the root cause for the denial – specifically if it is a payer issue or a practice issue. Looking at your top 25 payers, practices need to review the number of days in AR, paying particular attention to the greater than 90 days bucket.

You need to ensure your staff or outsourced billing vendor are using the correct CPT codes and schedule monthly meetings asking staff to share issues they are having with specific payers that may need your attention. Practices should also scrutinize how modifiers are used and their impact on reimbursement.

By reviewing your contracts and identifying payment issues, you can create a matrix of important data points for each contract and begin the process of managing your revenue more accurately.

Armed with this information, you can look how your practice’s strengths, like clinical expertise, differentiated services and patient evaluations can help you negotiate with your payers to structure contracts which best represent your practice and the patients you serve for the best possible reimbursement.

If your practice is looking for a business intelligence tool that provides data and reporting, like payer fee schedule comparisons, physician performance against benchmarked data or days in AR, contact the InfoDive® team for a demonstration at