Is Your Payer Contract Negotiation Strategy Leaving Revenue on the Table?

Half of medical group leaders say it has been three years or longer since their last commercial payer rate increase, according to an August 2026 MGMA Stat poll. Over the same stretch, more than 8 in 10 groups report higher operating costs this year. That math doesn’t hold up for long, which is why payer contract negotiation belongs on your practice’s calendar, not just its wish list. 

Here’s the twist, though. A rate increase is only one part of a healthier payer relationship. In her webinar on negotiating with top payers, Stephanie Thomas, CPC, CANPC, COSC, makes the case that understanding your payer contracts, focusing on the services that matter most and confirming payments follow the agreement are just as important. Here’s how to put those ideas to work. 

Know What Your Payer Contracts Actually Say 

Start by gathering every payer contract, fee schedule and amendment your practice has signed. Then look closely at renewal dates, notice requirements and any windows to renegotiate. These details decide when and how you can ask for change, so they’re worth knowing cold. 

Thomas recommends reviewing contracts at least once a year rather than assuming automatic renewals will bring higher reimbursement. Often, they don’t. An auto-renewal can quietly lock in last year’s rates for another cycle while your costs keep climbing. 

Missing a contract? Don’t panic. Her suggested starting point is your payer representative or the payer’s credentialing department. 

Focus Your Fee Schedule Review on the Services That Matter Most 

Trying to renegotiate every code at once is a recipe for frustration. Thomas suggests beginning with your top 15 to 20 procedure codes and your major payers. For each one, compare service volume against reimbursement, using Medicare as a reference point. The CMS Physician Fee Schedule Look-up Tool is a handy place to pull those Medicare rates. Add more codes when needed to represent your practice accurately. 

Just remember that Medicare itself hasn’t kept pace. The American Medical Association reports that, adjusted for inflation, Medicare physician payment effectively declined 33% from 2001 to 2025. A useful reference point, in other words, isn’t the same thing as a fair rate. 

Keep different insurance products separate so your comparison stays meaningful. Then factor in what each service actually costs to deliver, including provider compensation, staff, supplies and overhead. A targeted request for one important procedure may get further than asking for the same percentage increase on every service. 

Look Beyond the Headline Reimbursement Rate 

A strong rate can lose its shine fast if the fine print works against you. Before renewal or renegotiation, the webinar highlights several contract terms that deserve a closer look: 

• Payment calculation. Does the contract pay the lower of your charge and the agreed rate, apply a percentage reduction or impose a payment cap? 

• High-cost services. Are implants, supplies and distinct services clearly defined and appropriately addressed? 

• Deadlines and changes. How much time do you have to submit claims, appeal decisions or respond to amendments and policy changes? 

• Risk and administrative cost. Who bears eligibility and repayment risk, how are disputes resolved and are fees deducted to receive payment? 

Each of these terms can chip away at what you actually collect, even when the headline rate looks healthy on paper. 

Build a Supported Request, Not a Blanket Ask 

Payers respond to specifics. Prepare a written proposal that sorts your priorities into three tiers: essential changes, desirable changes and ideal outcomes. That structure shows you’ve done the homework and gives both sides room to find middle ground. 

Next, make the case for the value your practice brings to the payer’s members. Think specialty access, extended hours or community services. Where a procedure is under-reimbursed relative to its cost, back up your request with supporting cost information. 

Track every request, response, agreed change and follow-up date. And always start with the actual notice and renewal requirements in your contract. General outreach timing from a webinar, including this one, shouldn’t stand in for the dates your agreement spells out. 

Verify the Increase Reaches Your Payments 

Winning a better rate feels great. Making sure you’re actually paid that rate is where the real work begins. Confirm when the new rates take effect, which products and procedure codes they cover and whether any adjustment applies retroactively. 

Don’t assume one higher payment means the increase is in place across the entire agreement. Thomas suggests reviewing 5 to 10 explanations of benefits (EOBs) per payer each month as a starting point. Compare those payments with the updated fee schedule, contact the payer about any differences and track each one through resolution. 

Then keep going. Periodic reviews after the initial change help catch underpayments before they add up. It’s the same principle behind healthcare revenue cycle enhancement, and it’s how one practice we worked with increased its profits by 900%. 

Come to Your Planning Conversation Prepared 

Before you sit down with your James Moore advisor and billing leader, gather the essentials: your major payer contracts and rate schedules, recent production and payment reports by procedure and payer, selected EOBs, key cost information and a list of upcoming renewal dates or recurring reimbursement problems. 

Then open with one question: Which payer relationships deserve attention first, and what information would support a well-prepared request? 

Keep Your Expectations Grounded 

Any numerical rate targets shared in the webinar are the presenter’s suggested negotiating objectives, not guaranteed increases or universal standards. Contract terms, deadlines and available protections need review for your particular agreement. And decisions about network participation or restricting new patients deserve separate consideration with your contracting and legal advisors. 

Make Payer Contract Negotiation a Year-Round Habit 

Know your contracts, use your own service and cost data, negotiate specific priorities and verify that agreed improvements show up in your payments. Practices that treat payer contracts as an active part of their revenue strategy, rather than paperwork that renews itself, walk into every renewal in a stronger position. Not sure which payer relationship to tackle first? Our physician practice CPAs can help you gather the data, sharpen the ask and confirm the results, so talk to our healthcare team today. 

This article is adapted from How To Negotiate Your Contract With Top Payers & Increase Revenue?, presented by Stephanie Thomas, CPC, CANPC, COSC, Audio Webinars, including the electronic transcript and accompanying handouts. This educational overview is not a substitute for a review of your specific contracts or legal advice. 

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