Revenue Cycle Insider

Use this tool to track contract specifics with each payer.

Staying on top of each contract for each payer is a complicated endeavor. In her HEALTHCON 2025 presentation “Do You Know Your Contracts?”, Jerrilyn Ivey offered tips on constructing a matrix to better keep track of all of the particulars.

Use these tips to simplify your own contract tracking, and then you can share information easily with everyone who needs to know in your organization. If you already have a payer matrix, look to see where you can integrate Ivey’s tips.

Review Contracts and Create a Matrix

Start with the most basic details: the payer name and the respective plans, since there are different rates for different plans, and the effective date, Ivey said.

“The effective date is important, because if the provider is not credentialed on that date of service and you submit a claim, they’re not going to pay it,” she said.

Then you need to collect details on the term, expiration date, and notification period.

Term includes how long the contract is for, which is often somewhere in the sphere of three to five years.

Keep in mind that sometimes, smaller terms can be useful. “I have a practice that just started up a year ago, and they were very fortunate to get all but one of their contracts on a 24-month or 12-month or a year, so that they could renegotiate a year after. They were in a hurry to get the practice set up and didn’t want to take the time to negotiate the rates. They just wanted to sign contracts. Here we are a year later, and we’re negotiating the contracts and looking at those a little closer. That effective date is important because we have to do it within the period they allow us to,” Ivey said.

Expiration dates can vary, and many contracts go evergreen until you actively approach the plan to renegotiate, she explained.

The notification period is commonly around 90 days, Ivey said, and you need to know the expiration date so you can calculate the date the notification period begins. Many plans won’t entertain negotiations until the notification period.

Navigate Plan and Pay Rates

There are at least four different types of payer rates. One common type is a percentage of Medicare: one event that could be the current year of Medicare or previous year, she said. Similarly, a Medicaid plan has a Medicaid rate.

Some plans also have tiered rates, where they pay people with MDs or physician assistants (PAs) different rates.

There are also proprietary rates, which essentially means that the payer has created their own fee schedule, Ivey said.

In these situations, it would be helpful for practices to be able to access the full proprietary fee schedule, but many payers prefer that practices instead specify, say, 100 codes.

“So, then you’re going to have to pull a report. Find your top 100 codes again. If you’re doing more than 100 codes, you may have to ask them again in three months,” she said. “These proprietary fee schedules are really difficult. Even sometimes they’ll tell you that this fee schedule is based off of a Medicare rate, and they’ll tell you what the percentage is, but it’s not a 1-to-1 match. So you’re safer getting their fee schedule, because that’s what they’re going to hold to: whatever their proprietary fee schedule is.”

There are also scenarios that involve mixed fee schedules, where certain codes or conversion factors might be paid at different rates, like for an evaluation and management (E/M) code versus a radiology code. In those situations, “you have to look at that mixture and make sure that you’ve got it very well documented, because when you’re doing your variance reports, that’s going to be important to know,” Ivey said.

Keep in Mind Other or Minor Aspects, Too

Payers may pay for services conducted via apps at a different rate. The going rate for Medicare is approximately 85 percent, which, “when you see that in the contract, that’s great,” Ivey said.

She said she has seen other commercial plans paying around 80 percent, and that practices could use the Medicare standard to possibly renegotiate the rate higher.

Don’t forget about precertification requirements, either. This can be an important addition to the matrix, but it can be hard to find. Sometimes they’re stipulated in the contracts, but more often, payers direct providers/practices to where the policies are posted online.

Timely filing is a crucial piece of information to know because it’s the framework in which you must operate to get paid. Many contracts say 90 days, but some are as long as six months or as few as 60 days. When you’re renegotiating contracts, focusing on timely filing can be important, especially if there are surgeons in your practice, because they may need a bit more time to get everything together, Ivey said. She pointed out that explaining why you need a longer time to file a claim can be a huge help in getting your wish.

Appeal filing is also important to track and keep in mind because your revenue cycle management (RCM) team depends on those deadlines to secure another chance at reimbursement. Knowing the specifics is crucial to making sure your RCM team has enough time to do their work, Ivey said.

Remember, this date is “not from the date of service, but from the time the claim is denied or underpaid,” she explained.

Payment disputes are another important aspect of the matrix: When preparing an appeal, you may have been paid but need to pursue the remainder of what you feel you’re owed. To dispute a payment, you need reports on underpayments and variance.

Timely payment is another factor you may want to track, and this may differ from state to state. Beware that electronic claims and paper claims may have different dates, too. Some states also have prompt pay protections for providers that penalize payers when they pay late. In these cases, some payers may proactively pay, based on a calculation per day, when they know they’ve paid late, Ivey said.

Put Everything Together

Once you have all of this information collected, you can put it all into a spreadsheet — and put any important/relevant dates in a corresponding calendar — and make sure you share it with your RCM team. 

You can use this information to expand your knowledge and, thus, your confidence.

“When we have this information at our fingertips, we’re going to be more confident when we are talking to our payers. We’re going to be more confident when we’re following up on our claims. Whatever our role is, we’re going to be a little bit more confident in that,” Ivey said.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC